
Class j££jCk. 
Book 7 UJ 47 



OopightN - 



COPYRIGHT DEPOSIT 



. 



A MANUAL OF FEVER NURSING 



WILCOX 



A MANUAL 



OF 



FEVER NURSING 



REYNOLD WEBB WILCOX, M.A., M.D., LL.D. 

PROFESSOR OF MEDICINE IN THE NEW YORK POSTGRADUATE MEDICAL SCHOOL 
AND HOSPITAL; CONSULTING PHYSICIAN TO THE NASSAU HOSPITAL ; VISIT- 
ING PHYSICIAN TO ST. MARK'S HOSPITAL; FELLOW OF THE AMERICAN 
ACADEMY OF MEDICINE; MEMBER OF THE AMERICAN 
THERAPEUTIC SOCIETY, ETC. 



flllustratefc 



PHILADELPHIA : 
P. BLAKISTON'S SON & CO. 

1012 WALNUT STREET 
I904 



LIBRARY of CONGRESS 
Two Copies Received 
APR 21 1904 
? Copyright Entry 

CLASS & XXc. No. 

COPY B 



-PLC i5 ^ 



/» 



14- 7. tf? 



Copyright, 1904, by P. Blakiston's Son & Co. 



PREFACE. 

This volume contains the lectures on fever nursing 

which were delivered in substance to the nurses of St. 

Mark's Hospital during the season of 1903-4. It is 

believed that the subject has been very completely and 

comprehensively treated and in accordance with the 

present state of practice. The work of preparing the 

manuscript for the printer, reading proof and making 

index has been very conscientiously performed by 

Doctor Henry Hubbard Pelton, to whom the author 

would extend his most appreciative acknowledgment. 

New York City, 
April, 1904. 



111 



TABLE OF CONTENTS. 

Page. 

PREFACE iii 

CHAPTER I. 
Fever. 

Definition : Causes : Physiology : Varieties : Lysis : Crisis : 
Recrudescence: Relapse: Normal and Abnormal Tem- 
perature : Symptoms 9 

CHAPTER II. 

Fever {Continued). 

Diagnosis : The Thermometer : Scales of Thermometry : 
The Taking of Temperatures : The Pulse : The Res- 
piration : Temperature Charts 28 

CHAPTER III. 

Fever {Continued). 

General Treatment: Hydrotherapy: Treatment of Special 
Symptoms : Feeding : Beverages : Diet in Convalescence : 
Diet-list 42 

CHAPTER IV. 

Fever {Continued). 

The Nurse: The Sick-room and its Furniture: The 
Patient: Quarantine: Disinfection 71 



vi TABLE OF CONTENTS. 

CHAPTER V. 
Infections of Continued Type. 

Page. 
Enteric Fever: Paratyphoid Fever: Weil's Disease: 
Typhus Fever: Yellow Fever: Influenza: Malta Fever: 
Mountain Fever : Acute Miliary Tuberculosis : Chronic 
Pulmonary Tuberculosis 87 

CHAPTER VI. 

Infections of Continued Type with Local Manifestations. 

Pneumonia: Diphtheria: False Diphtheria: Acute Articu- 
lar Rheumatism : Erysipelas : Septicemia : Puerperal 
Fever: Pyemia: Mumps: Bubonic Plague 144 

CHAPTER VII. 

Infections of Intermittent Type. 

Malarial Fever : Relapsing Fever : Dengue 182 

CHAPTER VIII. 

The Exanthemata. 

Scarlet Fever : Smallpox : Chickenpox : Measles : Ger- 
man Measles : The Fourth Disease of Dukes : Epi- 
demic Cerebrospinal Meningitis 194 

CHAPTER IX. 

Thermic Fever. 

Heat Exhaustion : Insolation 225 

INDEX 229 



ILLUSTRATIONS. 

Page. 

The Clinical Thermometer 28 

Specimen Temperature Chart (obverse) 39 

Specimen Temperature Chart (reverse) 40 

Clinical Chart of Enteric Fever 93 

Clinical Chart of Typhus Fever 117 

Clinical Chart of Yellow Fever 121 

Clinical Chart of Lobar Pneumonia 147 

Clinical Chart of Acute Articular Rheumatism 165 

Clinical Chart of Malarial Fever 185 

Clinical Chart of Relapsing Fever 190 

Clinical Chart of Scarlet Fever 197 

Clinical Chart of Smallpox 205 

Clinical Chart of Measles 216 



CHAPTER I. 

FEVER. 

Definition: Causes: Physiology: Varieties: Lysis: Crisis: 
Recrudescence: Relapse: Normal and Abnormal Tempera- 
ture : Symptoms. 

Fever. — Synonym, pyrexia. Fever, in the ordinary 
acceptance of the term, is understood to signify an ab- 
normally high bodily temperature. In the present 
state of our knowledge, however, it must be considered 
as a group of symptoms caused by some derangement 
of the chemistry of the body which may be the result 
of a variety of causes. These causes may act from 
within, being generated in the body, or from without, 
having been introduced into the body. In either case 
they act by affecting the nervous system. For in- 
stance, fever may result from the failure of the body 
to throw off certain excrementitious products, as in 
cases of uremic poisoning ; from certain changes in the 
blood, as in cases of anemia; from exposure to ex- 
tremes of heat, as in sunstroke ; from various intestinal 
disturbances ; from mental abnormalities, as in hysteria. 
Most often, however, rises of bodily temperature are 
due to the products of bacterial infection. The bac- 
2 9 



io FEVER NURSING. 

teria as they grow in the body throw off certain poison- 
ous substances which are taken up by the circulating 
blood and affect the nervous mechanism which controls 
bodily heat. 

It is believed that in the central nervous system a 
center or centers exist which control the heat produc- 
tion and the heat radiation (the two factors which regu- 
late the temperature) of the body. Fever, therefore, 
is the result of the abnormal working of this nervous 
mechanism. 

Heat production and heat radiation being responsible 
for the maintenance of a fairly constant bodily tem- 
perature, it follows that when variations from this tem- 
perature occur, they must be the result of abnormalities 
of these factors. Thus fever may follow an increased 
heat production, a diminished heat radiation, or any 
other lack of proper ratio between the workings of 
these two functions. As a matter of fact, however, the 
most usual cause of fever is an increased production 
of bodily heat. Abnormalities of heat radiation are 
rare. 

The word " fever " is incorporated in the designa- 
tions of certain diseases of which, to the superficial 
observer at least, the chief manifestation is a rise in 
bodily temperature. Of these diseases, which are 
sometimes spoken of as the essential fevers, typhoid 
fever may serve as an example. However, in these dis- 
eases as in all others the fever, that is, the high bodily 



TYPES OF FEVER. n 

temperature, is merely a part of the clinical picture, or 
in other words only a symptom. 

Fevers are spoken of as continued, intermittent or 
remittent. A continued fever is one in which the 
temperature maintains a continued high level with only 
slight variations. Typhoid fever may be taken as an 
example of this type. An intermittent fever is one 
marked by periods when the temperature may fall to 
normal or even below this point, but only to rise again. 
Of this type ordinary malarial fever may serve as an 
example. A remittent fever is one characterized by a 
temperature continuously above the normal, and which 
falls and rises but is without intermissions. Remittent 
malarial fever may be considered as an example of this 
class. 

Again, fevers are classified as sthenic (dynamic) and 
asthenic (adynamic). A sthenic fever is one charac- 
terized by a hot, dry skin, thirst, full, strong, rapid, 
tense pulse, high temperature and perhaps active de- 
lirium. An asthenic fever is one in which the skin 
is cold and clammy, the pulse feeble, and the nervous 
system depressed. 

In rare cases what is called an inverse fever occurs. 
In this type the elevation is highest in the morning and 
lowest in the evening, the opposite of the usual rule. 

The return of an elevated temperature to normal is 
known as the defervescence. This may take place by 
a gradual fall with intermissions during which there is 



12 FEVER NURSING. 

a rise but not to so high a point as that at which the fall 
began, and, as a rule, each successive rise is less than its 
predecessor ; a defervescence of this character is called 
a defervescence by lysis. At the termination of typhoid 
fever the temperature drops in this manner. When a 
temperature falls to normal or below this point in the 
course of a few hours the defervescence is spoken of as 
occurring by crisis. The usual defervescence in lobar 
pneumonia is of this type. 

After defervescence has taken place a rise of tem- 
perature lasting for only a short time sometimes hap- 
pens; this is spoken of as a recrudescence. Such a 
circumstance is usually due to some insignificant and 
often unaccountable cause. When the fever and the 
other symptoms of the original disease return it is evi- 
dent that re-infection has taken place and this mani- 
festation is known as a relapse. To guard against 
the possibility of such occurrences, and in order that 
they may be immediately detected it is wise to take the 
temperature at least once in the day, preferably in the 
evening, for a number of days after it has become 
normal. 

The temperature of convalescent persons is much 
more easily affected than that of those in health. 
Errors in diet, constipation, too much muscular exer- 
tion or mental excitement are often followed by rises 
of temperature in such cases. A rise of three degrees 
or more may signify the onset of some complication or 



BODILY TEMPERATURE. 13 

a relapse and consequently should immediately be re- 
ported to the attending physician. Sudden falls in 
temperature are likely to indicate collapse. In apo- 
plexy and febrile diseases a considerable rise in tem- 
perature often takes place just before death, while in 
chronic wasting diseases the temperature may be sub- 
normal for a number of hours before the end finally 
takes place. The temperature of infants and young 
children is much more easily influenced than that of 
adults, and consequently even slight constitutional dis- 
turbances may cause a fever of considerable height. 

Bodily temperature is nearly the same in all parts of 
the body, which may be accounted for by the fact that 
all parts are supplied by the blood, one of the functions 
of which is the distribution of heat. The average tem- 
perature of the human body in health is 98.6 F. 
(37 C), but any temperature from 97.5 ° F. (36.5 
C.) to 99.5 F. (37. 5° C.) is not considered abnormal, 
since bodily heat may be influenced by various factors 
even when disease is absent. The temperature of the 
body uninfluenced by disease may vary thus : 

(a) With the time of day. It is usually highest 
from four to seven o'clock P. M. Its maximum is 
maintained for three or four hours when a slow and 
gradual drop begins, lasting until from two to six 
o'clock A. M., at which time its minimum is reached; 
consequently at this time vitality is at its lowest ebb. 
As the morning progresses a gradual rise takes place 



14 FEVER NURSING. 

until the normal 98.6 F. (37 C.) is reached. In 
persons who sleep by day and work at night the tem- 
perature is lowest in the evening and highest in the 
early morning. 

(b) With the performance of bodily functions. 
There is usually a slight elevation after a full meal due 
to the active performance of digestion, and also during 
muscular exercise, though, if at this time there is pro- 
fuse perspiration, there is, as a rule, a decrease in the 
bodily temperature. 

(c) With the part of the body used in measuring 
the temperature. These variations are slight and of 
no importance. Rectal or vaginal temperature is 
slightly higher than that of the mouth or axilla. The 
sensation imparted to the hand by the feel of the body 
is no guide to the height of the bodily temperature, 
though at times fever may be suspected and later 
proven by the use of the thermometer. 

(d) With the age of the individual. In the infant 
it is slightly higher than in the adult and in old age it 
is a trifle lower, as the following table shows : 

Normal temperature in the infant. . 99.5°F. (37.5°C.) 
Normal temperature under 25 years. 99 °F. (37.2°C) 
Normal temperature about 40 years. 98.8°F. (37.i°C.) 
Normal temperature in old age.... 9&6°F. (37 °C.) 

(e) With the season of the year. Bodily tempera- 
ture is very slightly higher in summer than in winter. 



BODILY TEMPERATURE. 15 

A temperature above or below the limits previously 
indicated, signifies the existence of some abnormality 
of the functions of the body, and often the degree of 
the severity of this departure from the normal is in 
direct ratio to the height of the fever. Bodily tempera- 
ture may, however, descend as low as JJ° F. (25 C.) 
or ascend as high as 108 F. (42.5 ° C.) without death 
resulting, but such extremes, when maintained for any 
considerable period of time, almost invariably terminate 
life. Extraordinary cases are on record of very low 
and high temperatures. After long exposure to severe 
cold a temperature of 75 ° F. (24 C.) has been noted 
and the individual has recovered, and cases of sun- 
stroke have occurred in which the temperature has 
risen to 112 F. (44.5 C.) without causing death. 

In hospitals patients are sometimes found who will 
cause the column of mercury in the thermometer to 
rise to very unusual heights. This is accomplished by 
shaking the instrument or by rubbing its bulb upon 
the bed clothing. Such patients are usually maling- 
erers, and if carefully watched can be detected and 
prevented from practicing such deceptions. 

In shock, after hemorrhage, in certain forms of ner- 
vous disease, during marked alcoholic intoxication, 
especially if the individual has been exposed to cold and 
damp weather, and in any other condition producing a 
considerable weakening of vitality and a consequent 
condition of collapse a subnormal temperature may 
exist. 



1 6 FEVER NURSING. 

The various ranges of bodily temperature may be 
classified thus : 

Temperature of collapse. 95 - 97°F. (35 °-36.i°C.) 

Subnormal temperature. . 97 - 98°F. (36.i°-367°C.) 

Normal temperature 98 - 99°F. (36.7°-37.2°C) 

Temperature of " fever- 

ishness " 99°-ioo°F. (37-2°-37^°C.) 

Slight fever ioo°-ioi°F. (37.8°-38.4°C.) 

Moderate fever i02°-i03°F. (38.9°-39.5°C.) 

High fever i04°-io5°F. (40 °-40.5°C.) 

Intense fever i05°-io6°F. (40.5°-4i.i°C.) 

Hyperpyrexia io6°F. (4i.i°C.) and above 

An elevation in bodily temperature is, as a rule, ac- 
companied by certain symptoms referable to the vari- 
ous tissues and organs. Not all these symptoms show 
themselves in every case and they may not all be present 
in a selected case, but many of them are likely to be 
noticed in a patient who has any considerable rise in 
temperature. In certain diseases various of these 
symptoms may be particularly marked, and this fact 
often is of great aid in diagnosis. Instances are the 
conjunctivitis that usually accompanies measles and 
the sore throat that is a feature of the onset of scarlet 
fever. If the fever is caused by inflammation localized 
in any part of the body, there are usually manifesta- 
tions which call the attention of both the patient and the 
observer to this part. As an example the pain in the 
chest, the cough, and the shortness of breath of pneu- 



SYMPTOMS OF FEVER. 17 

monia immediately suggest some interference with the 
proper action of the lungs. 

Febrile diseases in the adult are usually ushered in 
by a distinct chill, with marked shivering, pallor, blue- 
ness of the lips, chattering of the teeth and inability to 
keep warm, no matter how thickly covered, or by chilly 
feelings of greater or less severity. In the child it is 
often a convulsion, which may vary in intensity from 
slight muscular tremors of face and extremities to dis- 
tressing movements of the entire body, which indicates 
the onset of fever. Following the initial chill or con- 
vulsion the rise in temperature, accompanied by other 
symptoms, appears. 

The Symptoms of Fever. 

Symptoms Referable to the Skin. — The skin is as 
a rule hot and dry and the patient complains that there 
is " fever " or that he " feels feverish/' although it is 
quite possible for the temperature to rise to 102 - 
104 F. (38.9 -40 C.) without being noticed by the 
patient. At times, and more often in some diseases 
than in others, the skin may be damp with a cool per- 
spiration. Various eruptions associated with the dif- 
ferent eruptive fevers may appear. These will be de- 
scribed later. 

Tiny vesicles (water blisters) may show themselves, 
often in great numbers, upon various parts of the body ; 
these need cause no alarm since they indicate nothing 



1 8 FEVER NURSING. 

worthy of notice. Delicate skins often show a general 
rosy blush which pressure with the finger-tip causes to 
disappear, but which immediately reappears upon re- 
moval of the pressure. This phenomenon is probably 
due to an increased quantity of blood in the cutaneous 
capillaries. In the late stages of fevers the outer layers 
of the skin are likely to scale off. Especially is this 
a feature of the eruptive diseases. At times large 
pieces of epidermis may be peeled off, notably after 
typhoid fever, when the skin of the fingers or toes may 
come away almost intact, forming veritable " moulds " 
of the parts. 

Symptoms Referable to the Mucous Membranes. 
— The so-called " fever sore " {herpes labialis) is likely 
to be present, especially in malaria and pneumonia. 
There is, even early in fevers, thirst and a tendency to 
dryness of the mouth and tongue. The latter may be 
of brighter pink than normal or coated with a grayish 
or whitish fur, swollen and often shows indentations 
caused by the teeth. As the fever reaches its height the 
upper lip may be drawn back so as to show the teeth, 
and the tongue and lips become covered with a dirty, 
brown, foul, viscid deposit, consisting of food particles, 
cells from the lining of the mouth, mucus and bacteria, 
which is termed sordes. The lips may become fissured 
and the gums spongy and bleeding. At first the tongue 
may be coated only down its middle while its margin is 
redder than normal; as the disease progresses the 



SYMPTOMS OF FEVER. 19 

tongue may tend to become dry at night while it remains 
moist by day. When the fever becomes very severe it 
may be difficult for the patient to extend the organ and 
it becomes tremulous, brown, dry, crusted and cracked. 
Bleeding from the fissures readily takes place. As the 
patient recovers the tongue gradually assumes its nor- 
mal appearance, which process begins at the tip and 
extends progressively backward. 

The pharynx is at first dry and may be the seat of a 
catarrhal inflammation, the tonsils and fauces may be 
swollen or ulcerated. The characteristic appearances 
of the throat in scarlet fever, diphtheria, etc., will be 
described in the sections devoted to those diseases. 
The salivary glands may be swollen and tender. The 
mucous membranes of the nose and eyes are likely to 
be congested and their secretions may be increased. 
There may be nose-bleed, especially early in typhoid 
fever. 

Symptoms Referable to the Organs of Digestion. 
— The appetite is greatly diminished or entirely absent. 
The mere thought of food may be distasteful to the 
patient. At the onset of febrile disease nausea is com- 
mon and vomiting often follows. Gas in the intestine 
is a less common symptom. It usually causes little dis- 
comfort and may not be worthy of notice except in 
typhoid fever, in which disease it frequently occurs and 
is the result chiefly of a paralysis of the muscular coat 
of the bowel caused by the general infection rather than 



20 FEVER NURSING. 

that of the presence and growth of the bacteria in the 
intestine. Usually in fevers the bowels are constipated. 
Diarrhea formerly was considered a feature of typhoid 
fever, but constipation is frequently present. 

Symptoms Referable to the Circulatory System. — 
The usual pulse of febrile disease is one of increased 
force and frequency and of high tension. As a rule the 
increase in these qualities is proportionate to the height 
of the temperature as the following table shows, though 
in certain patients the acceleration may not be marked 
even with high fever. 

Temperature of 98°F. (36.7°C.) corresponds to a pulse of 60 

Temperature of 99°F. (37.2°C.) corresponds to a pulse of 70 

Temperature of ioo°F. (37.8°C.) corresponds to a pulse of 80 

Temperature of ioi°F. (38.4°C.) corresponds to a pulse of 90 

Temperature of I02°F. (38.9°C.) corresponds to a pulse of 100 

Temperature of I03°F. (39.5°C.) corresponds to a pulse of no 

Temperature of I04°F. (40 °C.) corresponds to a pulse of 120 

Temperature of io5°F. (4o.5°C) corresponds to a pulse of 130 

Temperature of io6°F. (4i.i°C.) corresponds to a pulse of 140 

In children the pulse is particularly susceptible 
to rises of bodily temperature, rates of 150 to 
190 per minute not being uncommon. In adults 
a rate of no to 130 is not infrequently observed, 
feebler and smaller; in extreme cases it may become 
so rapid and weak as to be uncountable and impart 
merely a sense of undulation to the finger — the so-called 
running pulse. A dicrotic pulse (one with a double 



SYMPTOMS OF FEVER. 21 

beat), an intermittent pulse or one irregular in force 
and frequency is an indication of heart weakness. Any 
sudden increase in the rapidity or weakness of the pulse 
is likely to indicate the onset of some complication. 
Position, muscular action and emotional excitement 
influence the strength and rapidity of the pulse to a 
considerable degree. Consequently in fevers the re- 
cumbent position should be insisted on, for conservation 
of the heart's strength may be a considerable factor in 
the preservation of the patient's life if the disease prove 
a protracted one. 

Symptoms Referable to the Respiratory System. — 
In fever the number of respirations per minute may be 
slightly increased, and the depth of the breathing dimin- 
ished even when no lung involvement is associated with 
the disease. There may be cough due to an accom- 
panying bronchitis. When pulmonary involvement co- 
exists the respiration may be rapid, irregular and pain- 
ful. In marked pulmonary disease the breathing may 
become very difficult or impossible when the patient is 
lying and it may be necessary to allow him to sit up in 
bed with his back supported by a rest. When cough 
exists it is often accompanied by expectoration, the 
character of which will be described in the sections 
devoted to the febrile pulmonary diseases. Specimens 
of this should be retained for examination by the 
physician. 



22 FEVER NURSING. 

Symptoms Referable to the Urinary System. — The 
urine of a beginning fever is less in quantity than in 
health, of higher specific gravity, of darker color and 
possibly turbid. It may cause a burning sensation on 
being passed, due to its increased acidity. As the dis- 
ease progresses toward recovery the quantity increases 
and the urine becomes more nearly normal in other re- 
spects. In convalescence the quantity may be even 
greater than in health. Fever urine on standing often 
deposits a red or reddish-brown sediment, consisting 
usually of uric acid or urates, which are the products 
of the unusual tissue changes which take place during 
febrile conditions. In severe febrile disease albumin, 
casts and even blood may appear; these, however, do 
not of necessity indicate permanent impairment of the 
kidneys. Retention of urine is a rare concomitant of 
fever. 

Symptoms Referable to the Nervous System. — 
The initial chill or convulsion of fever has been dis- 
cussed above (p. 17). When a chill manifests itself in 
the course of a fever it is likely to signify a sudden 
alteration for the worse in the patient's condition or the 
onset of a complication. Consequently such an event 
should be immediately reported to the attending physi- 
cian. The convulsion of beginning fever, as a rule, is 
not the result of any change in the nervous system but 
is caused by the poison of the disease. Convulsions 
developing later in febrile disease not involving the 



SYMPTOMS OF FEVER. 23 

nervous system are rare and may be due either to 
hysteria or to the presence in the system of substances 
which should have been eliminated through the kid- 
neys. Urinary examination may throw light upon the 
causation of such convulsions, hence it is important that 
the nurse should secure a specimen at the earliest oppor- 
tunity. 

Headache is one of the most frequent symptoms of 
the onset of fever. It may vary from a dull ache of 
slight character to an intense, persistent and almost 
unendurable pain. At times it may be of neuralgic 
type. The pain is usually in the forehead or temples ; 
more rarely it occurs in the top or back of the head. 
As the disease progresses it is likely to abate in vio- 
lence. 

Pains in the back and limbs and in the bones often 
are associated with the headache and also may vary in 
intensity from a mere discomfort to the severe pain in 
the back associated with smallpox or the marked bone- 
ache of epidemic influenza. 

Dizziness or vertigo often exists during the inception 
of febrile disease. This is increased when the patient 
stands and is much relieved by the recumbent posi- 
tion. Patients recovering from fevers of protracted 
length frequently are subject to dizziness due to weak- 
ness. 

Mental symptoms are very common manifestations 
during fevers. These vary from mere dulness, listless- 



24 FEVER NURSING. 

ness, apathy and indisposition to mental exertion to ex- 
tremes of delirium or even absolute coma. These 
symptoms differ with the temperament of the individ- 
ual; intellectual persons and those who, in their daily 
occupations, are accustomed to use the mental rather 
than the physical faculties, are most likely to suffer 
from disturbances of this character. Naturally the 
type and severity of the disease influence to a marked 
extent the degree of mental disturbance. Extremes of 
mental disorder generally manifest themselves when the 
disease is otherwise at its worst. 

Delirium is not unusual in severe fevers and may, 
though rarely, exist from the onset of the disease. 
More commonly it occurs later and varies in degree; it 
may be mild and appear only at night, it may be of quiet 
type or very violent, noisy, and so marked that restraint 
is necessary to control the patient. In other cases the 
delirium may be of the low, muttering type. When this 
occurs the patient lies quietly with his eyes open or 
closed, in a sort of half-waking state; he mutters in- 
coherently to himself in a low tone, taking no cogniz- 
ance of what is happening about him, and perhaps picks 
at the bed clothing or grasps at imaginary objects. He 
will respond sluggishly to a loud question and to active 
sensory impressions (a pinch or pin prick). He may 
make short replies, but relapses into his stupor, which 
may be troubled by dream-like hallucinations. These 
may disturb him even while he is in a half-waking con- 



SYMPTOMS OF FEVER. 25 

dition. While in this state restraint is unnecessary but 
the nurse's vigilance must not for an instant be relaxed 
for at any moment aggressive delirium of alarming 
character may appear. Habitual users of alcohol are 
likely, especially during the fever of pneumonia, to de- 
velop delirium tremens. Delirium of this type may 
attack even those who are unaccustomed to alcohol. 
Under this condition the patient talks constantly and 
incoherently. He is in motion continuously, there -is 
marked muscular tremor and he is unable to sleep ; he 
often shouts aloud, and frequently desires to rise, go 
out and attend to his work ; visual and auditory halluci- 
nations develop and he may see various imaginary ob- 
jects, especially animals, such as rats, snakes or insects 
and think that they are creeping about the bed. 

Delirium may pass on into stupor, a condition in 
which the patient lies quietly in a partially unconscious 
state, from which he may be aroused with some diffi- 
culty, but into which he slips again when the attempt 
to awaken him is discontinued, or a condition termed 
coma vigil may result. This is an unconscious state in 
which the patient lies with eyes open, but entirely ob- 
livious to all going on about him ; he neither realizes 
nor can he express his desires, he mutters constantly, 
his lips and tongue tremble and there are twitchings of 
his fingers and wrists (subsultiis tendinum) due to the 
convulsive jerkings of their tendons; he picks at the 
bed clothing and grasps at invisible objects. Such con- 
3 



26 FEVER NURSING. 

ditions as these may gradually disappear as the patient 
progresses toward recovery or absolute coma may 
supervene. This is a condition of entire insensibility, 
from which it is impossible to rouse him ; he lies practi- 
cally motionless, is unable to swallow and passes feces 
and urine involuntarily. Such a state is usually, al- 
though not invariably, a precursor of death. 

Hiccough (singultus) is at times an obstinate symp- 
tom of fever. It is occasioned by a spasmodic contrac- 
tion of the muscles of the diaphragm and may con- 
tinue, despite energetic treatment, for considerable 
periods of time. 

Symptoms Referable to the Special Senses — Taste. 
— In fever the sense of taste is rendered less acute, per- 
verted, or, exceptionally, wholly lost. Nothing tastes 
good, thirst is increased, water is always acceptable, 
and sour-tasting foods and drinks are preferred to 
sweet. 

Smell. — The sense of smell is frequently blunted 
owing to the catarrhal inflammation of the nasal mucous 
membrane which may accompany fever. Especially in 
typhoid fever, nose-bleed may be an early symptom. 

Hearing. — Hearing may be impaired, but is more 
usually rendered abnormally acute; there are often 
noises and ringing in the ears. Deafness is exceptional. 
The infectious fevers may be complicated by inflamma- 
tions of the middle ear. In such cases there is earache, 
which is lessened if the inflammation goes on to per- 



SYMPTOMS OF FEVER. 27 

foration of the drum-membrane. When this takes 
place a discharge usually appears, at first thin, yellowish 
and perhaps bloody. Later it becomes thicker in con- 
sistency and often foul. 

Sight. — There is often a dread of bright light (photo- 
phobia) and vision is less acute than normal. Usually 
early in fevers the pupils are dilated ; later there is no 
fixed rule for their condition. The lining of the lids 
frequently is inflamed ; its secretion is at first increased 
but later diminished, causing dryness. At times the lids 
may be gummed together. 

Fever is always accompanied by an increase of tissue 
waste, consequently emaciation to a greater or less de- 
gree is an inevitable result. This is all the more marked 
since, in addition to the tissue waste, there is disin- 
clination on the part of the patient to eat and probably 
inability on the part of the digestive and assimilative 
powers to supply the increased need of bodily nourish- 
ment. 



CHAPTER II. 

FEVER (Continued). 

Diagnosis: The Thermometer: Scales of Thermometry: The 
Taking of Temperatures: The Pulse: The Respiration: 
Temperature Charts. 

Diagnosis of Fever. — Fever being defined as an 
abnormal degree of bodily heat its diagnosis resolves 
itself into the measuring of the temperature of the 
body. It is customary as well to note, at the same time, 
the number per minute and character of the pulse beats 
and respirations. The height of bodily temperature is 
measured by means of the clinical thermometer. 

iMMIMliMM D 1 ' 1 ' 1 ' 1 ' 1 " ^ ^ 

*&^JL^M, gglSSSSte 1 8 *tn ,, ^Jj 



Clinical Thermometer. 

This little instrument is a form of maximum ther- 
mometer; that is to say an instrument so constructed 
that when its column of mercury reaches a certain 
height it remains there until displaced by jarring or 
shaking. The object of this is to give the observer 
sufficient time for accurate reading. Some clinical 
thermometers are provided with a curved surface which 
magnifies the column of mercury so that it is more 

28 



DIAGNOSIS OF FEVER. 



29 



easily read than in instruments not so constructed. 
Thermometers registering in one minute or less may 
be purchased, but in hospitals those requiring from two 
to five minutes are usually employed, since they are less 
expensive. 

There are in use at the present time three scales of 
thermometry, the Fahrenheit, the Centigrade and the 
Reaumur. The differences in these are as follows: 
They are all based upon the freezing and boiling points 
of water, the Fahrenheit scale taking 32 ° as the former 
and 212 as the latter, the Centigrade scale, o° and 
ioo°, and the Reaumur scale o° and 8o°. A table of 
comparisons of these scales is appended. 



Fahr. 


Cent. 


Reau. 


Fahr. 


Cent. 


Reau. 


Il6 


46.7 


37-3 


$6 


30 


24 


II 4 


45.6 


36.4 


84 


28.9 


23.I 


112 


44-4 


35.6 


82 


27.8 


22.2 


no 


43-3 


34.7 


80 


26.7 


21.3 


I08 


42.2 


33.8 


78 


25.6 


2O.4 


106 


41. 1 


32.9 


76 


24.4 


I9.6 


IO4 


40 


32 


74 


23-3 


18.7 


I02 


38.9 


31-1 


72 


22.2 


17.8 


IOO 


37.8 


30.2 


70 


21. 1 


16.9 


98 


36-7 


29-3 


68 


20 


15 


96 


35.6 


28.4 


66 


18.9 


I5.I 


94 


34.4 


27.6 


64 


17.8 


I4.2 


92 


33-3 


26.7 


62 


16.7 


13-3 


90 


32.2 


25.8 


60 


15.6 


I2.4 


88 


3i.i 


24.9 









Only the two former scales are in common use, the 
Fahrenheit in America and England, the Centigrade 
upon the continent of Europe; however, many physi- 



3° FEVER NURSING. 

cians in the United States prefer to use the latter scale. 
Certain rules may be formulated for the conversion of 
one scale into the other; for instance to convert a 
Fahrenheit reading into a Centigrade one subtracts 32, 
multiplies by 5 and divides by 9. To reduce a Centi- 
grade into a Fahrenheit, one multiplies by 9, divides by 
5 and adds 32. Examples : 

98.6 F. == (98.6-32 X 5 -*- 9) = 37-o° C. 
37° C = (37 X 9 -5- 5 + 3.2) = 98-6° F. 

In the text of this volume the Fahrenheit scale will be 
used with the Centigrade equivalent following in paren- 
theses. 

The index upon a clinical thermometer usually reads 
from 95 F. (35 C.) to no° F. (43.3 C.) or 112 F. 
(44.4 C), and each degree is divided into fifths so 
that one accustomed to the use of the instrument may 
easily read as closely as to the tenth of a degree. 

With use the accuracy of clinical thermometers be- 
comes somewhat impaired, owing to the action of dif- 
ferences in temperature upon the glass ; consequently it 
is wise from time to time to have them compared with 
a standard instrument. This may be done by holding 
both thermometers in a vessel of warm water and 
noting the difference in registration if any exist. 

In private practice each nurse should be supplied 
with two thermometers, to provide against breakage; 
it is wise to keep one of these for mouth and the other 



USE OF THE THERMOMETER. 3 1 

for rectal temperatures. In hospitals, especially in con- 
tagious disease wards, there should be a thermometer 
for each patient, and the nurses should take great care 
not to break the instruments as in a large institution the 
cost of the thermometer supply is by no means a small 
item. When not in use they should be kept in a small 
vessel, a tumbler for example, filled with an antiseptic 
solution (5% carbolic acid or 1 to 5000 mercury 
bichlorid). The bottom of the vessel should be cov- 
ered with a layer of absorbent cotton. Recently it has 
become possible to purchase thermometers in air-tight 
cases which may be filled with an antiseptic solution. 
The appliance is one to be recommended to those who 
carry the instrument in bag or pocket. 

Bodily temperature may be measured in the mouth, 
the axilla, the groin, the rectum or the vagina. In ordi- 
nary practice the mouth or axilla is usually used. The 
temperature varies within small limits depending upon 
the situation employed as the following table indicates : 

Axilla (groin) 98.4°F. (36.9°C.) 

Mouth 9&6°F. ( 37 °C.) 

Rectum (vagina) 99-5°F. (3/.5°C.) 

Before and after taking the temperature in any of 
these situations the thermometer should be washed in 
clean cold water, and the column of mercury shaken 
down as low as 95 ° F. (35 C). If the mouth is to 
be used, the nurse should make sure that no hot or cold 



32 FEVER NURSING. 

substance has been eaten or drunk for some time 
previously. The patient should be told to keep the in- 
strument upon the floor of the mouth underneath the 
tongue, to hold the lips tightly closed, lest outside air 
enter, and to breathe gently through the nose. If the 
thermometer is broken in the mouth and pieces are 
swallowed the physician should be notified immediately, 
although no bad results are likely to ensue. 

In using the axilla, the part should be wiped with a 
moist sponge or cloth, and then thoroughly dried with a 
towel. The bulb of the instrument should be placed 
in the deepest part of the arm-pit, the arm pressed close 
to the side and the forearm folded across the chest with 
the hand upon the opposite shoulder. The nurse must 
hold the limb in this position while the thermometer is 
in place. 

When taking the temperature in the rectum care 
should be taken that the bowel is empty, for if the 
thermometer does not come in direct contact with the 
mucous membrane it will not register the correct bodily 
temperature. The instrument should be lubricated 
with vaselin or other like substance, the buttocks gently 
separated with the fingers of one hand while the bulb 
of the thermometer is inserted through the anal opening 
for from one and a half to two inches. In struggling 
children and in delirious patients the nurse must take 
great care lest the instrument be broken within the 
bowel. In taking the temperature in the vagina the 



USE OF THE THERMOMETER. 33 

technique is practically the same as when the rectum 
is used. 

Taking the temperature in the groin is seldom neces- 
sary and the results are less accurate than in any of the 
other situations. 

It is wise to allow the thermometer to remain in place 
at least five minutes so as to be certain of accurate regis- 
tration. When there is local inflammation in or near 
the axilla, the mouth or the rectum, the local heat is in- 
creased over that of the rest of the body, consequently 
in such case an unaffected part should be used in meas- 
ing the bodily temperature. 

In every febrile condition the temperature should be 
taken at least twice during the twenty-four hours. 
Since the temperatures of the morning and evening in- 
dicate most exactly the progress and severity of the dis- 
ease, these are the most appropriate times. In diseases 
of severe type it is customary for the physician to order 
the temperature taken every six, four or three hours as 
he may deem necessary. Usually it is unwise to waken 
a patient in order to take his temperature, for the benefit 
derived from the sleep is likely to exceed that accruing 
from learning his temperature, but at times it may be- 
come necessary to take the temperature at the stated in- 
tervals at all hazards. Judgment on this point is, of 
course, left with the physician. 

The Pulse. — In taking the pulse two factors must be 
considered, first, its frequency; second, its quality. 



34 FEVER NURSING. 

The frequency of the pulse is affected by the same in- 
fluences which affect bodily temperature (see p. 13). 
It also differs in different individuals under the same 
conditions. One person in health may have a pulse as 
slow as 50 to 60 beats to the minute while another's may 
beat 80 to 90. Age and sex influence the pulse-rate as 
the following table shows : 

Normal pulse in children... 90-100 beats per minute 
Normal pulse in adult males. 60- 75 beats per minute 
Normal pulse in adult fe- 
males 65- 80 beats per minute 

In noticing the quality of the pulse the following 
points must be considered: 

(a) Regularity or irregularity. 

(b) Whether intermittency be present. 

(c) The size of the artery. 

(d) The character of the pulse wave. ■•:■ I 

1. Whether the rise be quick or slow. 

2. Whether the fall be quick or slow. 

3. Whether dicrotism be present. 

(e) The tension of the artery wall. 

(f) Whether the artery wall be abnormally thick. 

A pulse may be irregular in frequency, in force, or in 
both these elements. 

An intermittent pulse is one which drops a beat from 
time to time. 

The pulse wave as it is felt by the finger of the 
observer may rise and fall with varying degrees of 



THE PULSE IN FEVER. 35 

rapidity. A dicrotic pulse is one in which two distinct 
beats are felt for each pulsation of the heart. The first 
and greater of these is the true pulse beat and care 
should be exercised on the part of the nurse not to count 
the second and weaker impulse. In cases where it is 
difficult to distinguish the true beat from the false one 
hand should be placed on the chest over the heart's 
apex. When this is done the dicrotic pulse may be 
counted with ease and correctness. In this type of 
pulse, which occurs only when arterial tension is low, 
the second wave is due not to a contraction of the 
heart, but to the closure of the aortic valves. 

The tension of the artery wall depends upon two 
factors : Whether the muscular coat of the artery be 
contracted and whether the vessel be fully distended 
with blood. A pulse of high tension is not easily com- 
pressible by the finger and its condition is analogous to 
that of a rubber tube filled with water under heavy 
pressure. 

Thickening of the artery wall is determined by 
pressing the vessel so as to empty it of blood and then 
trying to roll it under the finger tips. If the empty 
vessel is more than slightly perceptible its wall may be 
considered as thickened. Thickness differs in degree 
from bare perceptibility to such marked thickening that 
the vessel feels like a pipe stem under the skin. 

The normal pulse is perfectly regular in force and 
frequency, the artery is of medium size, its rise and 



36 FEVER NURSING. 

fall are gradual, its tension is only moderate and the 
vessel wall is not thickened. 

Under normal conditions some individuals have an 
intermittent pulse, but such a condition is not a frequent 
occurrence. 

Impairment of the strength of the pulse, increase in 
its rapidity, intermittency and dicrotism are indications 
of heart weakness and are not unusual manifestations in 
febrile disease. 

The nurse should be watchful of the effects upon the 
pulse of various therapeutic measures such as baths and 
the different drugs. In disease pulse and temperature 
bear an important relation to one another, pulse fre- 
quency being increased as a rise in temperature takes 
place ; any disturbance of this ratio should be carefully 
noted by the attendant, since it may be an indication of 
heart weakness. 

In taking the pulse the radial artery in the wrist is 
the usual site for the procedure, although at times the 
carotid or temporal arteries may be found more con- 
venient. The nurse should accustom herself always to 
use the same fingers — usually the index and middle 
fingers of the right hand, because continued practice 
will result in extreme delicacy of touch. The pulse 
should be counted for at least one minute so as to in- 
sure accuracy. 

The Respiration. — In taking the respiration of a 
fever patient, as in taking the pulse, frequency and char- 



THE RESPIRATION IN FEVER, 37 

acter are the elements to be noted. Normally the num- 
ber of respirations per minute in the adult is in the 
neighborhood of eighteen, or one to about every four 
pulse-beats. The rapidity of respiration varies, as does 
that of the pulse, at different periods of life. 

Respirations in the infant 30-35 per minute 

Respirations in the child from 

five to eight years 20-25 per minute 

Respirations after eight years 

of age 18-20 per minute 

The normal pulse-respiration ratio may be modified 
in disease. In fevers without lung involvement the 
pulse usually undergoes a greater relative increase than 
do the respirations, while in cases in which the lungs are 
affected, the reverse of this rule is the usual condition. 

In observing the respirations the following character- 
istics should be noted : 

(a) Their frequency. 

(b) Their regularity. 

(c) Their depth. 

(d) Whether they be quiet or stertorous. 

(e) Whether they be abdominal or thoracic. 
Stertorous respiration is breathing accompanied by a 

sound resembling snoring. 

In children and adult males respiration is normally 
abdominal, that is to say the abdomen rises and falls 
upon inspiration and expiration rather than the chest, 
while in adult females thoracic respiration — breathing 
in which chest movement is more marked — is the rule. 



38 FEVER NURSING. 

While taking the respiration the nurse should not 
allow the patient to know what is being done, for this 
knowledge is likely to have such a mental effect as to 
influence the depth and rapidity of the breathing. 
Usually the respiration can be counted by watching the 
rise and fall of the chest or abdomen of the patient 
without his cognizance. In order to insure an accurate 
record the respirations should be counted for at least 
one minute. 

In children the act of crying frequently renders it 
quite impossible to estimate the respirations with any 
degree of accuracy. 

For recording the temperature, pulse and respiration 
printed or ruled charts are used which not only show at 
a glance the course of the disease in regard to these 
factors, but are valuable afterwards as documents of 
reference. Such a chart is depicted upon the opposite 
page. The method of recording the temperature, pulse 
and respiration is as follows : Suppose the patient is 
first observed in the morning and his temperature is 
101.2 F. (38.5 ° C), his pulse 95 beats per minute, 
and his respirations 20 per minute; dots are made 
upon the chart in the proper places. In the even- 
ing his temperature is found to be 102.4 F. (39. i° 
C), his pulse 115 and his respirations 25; dots 
are again made in the column for afternoon records 
and lines are drawn connecting these with those of the 
morning. The next day the process is repeated, and so 



TEMPERATURE CHART. 



39 



Name . 




















Aee 










Sex 




Dfae 


n 


osts 




















Case 


Nc 








DATE 
















42 


DAY OF 

DISEASE 
















HOUR 


A.M. 


P. ML 


A.M. 


P.-M. 


A.M. 


P.M. 


A.M. 


P.M. 


A.M. 


P.M. 


A.M. 


P.M. 


A.M. 


P.M. 


107 


I 1 




1 
















































































41° 


























































106 






















































































































































| 105 


































40° g 


































































































a 

g 104 




















































■ \ 














































































































g 103 




























































































































































































P o 










































































































i 




■ 




; i 




















i — 












3 

£ 101 






















































o 

S3 

38° =5 






/ 


































































































/ 






























































































« c 

H 100 






— 1 — r~ 




























— J 








— ; — — 








































































& 
































99 














































































































































i ' 




















































37 


98 










































36° 






i | 


















































































97 






i 








































. 














































! 












































































































































96 


















































































































































































































































































150 
















































































60 


















































































140 


















































































50 


















































































130 






























































































































































120 












































































40 £ 












































































w no 


























































































































































3 100 














































































30 | 












































































£ 90 




/ 


















3 








































































a 








































80 






























































o 

20 ^ 
















«_ 


«- 










































70 












iJ-l^" 






^ 
















































rT 








s; 




































60 












! 












































10 




























































50 


























































































■ 
















40 


















































































i 


















































NO. OF 
STOOLS 
























































| 

























4o 



FEVER NURSING. 



Examination 
of Urine 



Oz. 



Remarks 



Medication 



Diet 



General 
Remarks 



CHARTING TEMPERATURES. 41 

on. When the records are taken more often the method 
is the same, the chart being so arranged as to make the 
recording of the patient's condition every four hours 
very simple. Upon the right side of the chart will be 
found Centigrade and respiration scales. It is well to 
chart the night temperature curve and the respiration 
curve in red ink. The spaces for date, day of disease 
and number of stools will explain themselves. 

Upon the back of the chart will be found spaces for 
recording the urine examinations, the medication, the 
diet, etc. It is suggested that the notes for the night 
be made in red ink. 



CHAPTER III. 

FEVER (Continued). 

General Treatment: Hydrotherapy: Treatment of Special 
Symptoms: Feeding: Beverages: Diet in Convalescence: 
Diet-list. 

General Treatment of Fever. — At the first indica- 
tion of febrile disease, the patient should be put to bed 
and strict quiet enjoined. The problems that confront 
us in the management of such a patient are two ; first 
the removal of the cause and underlying factors so far 
as this is possible, and second the restoration of proper 
metabolism, the abnormal condition of which is shown 
by the various derangements of the bodily functions 
which are a part of the clinical picture. 

Frequently very little can be done to remove the 
cause of a fever, as this is self-limiting and its results 
are impossible of abortion or shortening; however, 
unless there exist some contraindication we may be 
able to lessen the effects of this cause by inducing elim- 
ination through various channels. This may be done 
by causing emesis, free movements of the bowels, in- 
creasing the quantity of urine, stimulating the action of 
the skin so as to induce free sweating, or by rectal irri- 

42 



TREATMENT OF FEVER. 43 

gation. The poison circulating in the blood may be 
rendered less harmful by the introduction of warm salt 
solution (o.7fc) under the skin or directly into the 
blood stream through an opening into a vein. 

By emesis irritating substances will be removed from 
the stomach and further infection by this re 
prevented, and the absorption of poisons through the 
stomach wall will be stopped. Free purgation will act 
in like manner upon the intestinal tract and also per- 
haps aid in removing toxic substances from the blood. 
The induction of free action of the skin and kidneys 
leads to a like effect, and the high recral irrigations, 
the injection of salt solution under the skin or directly 
into the circulation not only dilute the poisons but will 
hasten their elimination through the various channels 
and act as stimulants of considerable power upon the 
weakened system. 

By these means we may. very rarely, remove the pri- 
mary cause of the disease : when this is impossible we 
may lessen the severity of the process and accomplish 
much toward the restoration of normal metabolism and 
the correction of the disturbed body functions. 

In the less severe febrile diseases the abnormal tem- 
perature, which may run from ioi c F. (38.3* C.) in 
the morning to 103 ° F. (39.4° C.) in the afternoon. 
needs no special attention. When high temperature 
persists and is of itself manifestly a menace to the 



44 FEVER NURSING. 

patient, measures must be taken to mitigate it. This 
may be done: 

(a) By drugs. The various so-called antipyretics, 
phenacetin, acetanilid, antipyrin, etc., may be employed, 
but their use may be attended by bad effects, especially 
upon the heart, and their administration is fast passing 
out of vogue. Patients to whom these drugs are given 
must be carefully watched by the nurse for signs of 
heart-weakness. The fall of temperature following 
their use may be accompanied by various signs of pros- 
tration which will necessitate warm covering, the use 
of hot-water bottles and perhaps the administration of 
whiskey, aromatic spirit of ammonia or other stimulant. 
Consequently the reduction of fever by drugging is to 
be attempted with the greatest care if at all. 

(b) Much more advisable is the control of high tem- 
perature by means of cold applied externally. This 
may be done in various ways as follows: 

i. The Cool Tub Bath. — This necessitates at least 
two attendants, for the patient must be lifted into the 
tub, which should be placed at the patient's bedside. It 
should contain water enough to cover the patient to the 
neck, the head should be supported upon a rubber air 
pillow attached to the edge of the bath tub and his 
comfort will be augmented by placing a rubber air 
cushion beneath the buttocks. The temperature of the 
water may be varied within wide limits, but may not be 
lower than 59 F. (15 C). If the cold water is dis- 



BATHS IN FEVER. 45 

agreeable the bath may be begun at a temperature of 
90 F. (32.2 C.) and cold water gradually added until 
the temperature is reduced as low as required. It is 
better, however, to use cold water from the beginning 
for the effect sought is a reaction and for this a certain 
amount of shock is necessary. The patient, wearing 
swimming trunks or covered with a sheet, should be 
gently lifted by two attendants and lowered into the 
water. Cold water — 6o° F. (15 C.) or less — should 
be poured over the head or a frequently changed cool 
compress should be applied to the forehead. The cold 
water may be applied to the head by means of a cur- 
rent from an ordinary irrigating apparatus. Vigorous 
rubbing of the body by the hands of the attendants 
throughout the bath is an absolute necessity. The 
bath should last from ten to twenty minutes according 
to the reactive power of the patient. At the end of the 
procedure the patient should be lifted out of the tub 
and placed in bed, the water having been allowed to 
drain off for a few seconds to prevent wetting the 
blankets. Now being wrapped in the blankets he 
should be thoroughly dried by rubbing. If the patient 
shows signs of poor reaction while in the bath such as 
blueness of the lips and extremities or decided shivering 
or if the effect upon the heart is untoward the duration 
of the bath should be lessened. In most patients chat- 
tering of the teeth may be disregarded, and cyanosis of 
the extremities alone need not be considered sufficient 



46 FEVER NURSING. 

reason for stopping the bath, but if marked blueness of 
the face, especially about the nose, is noticed the patient 
should be immediately taken from the water. The 
patient's temperature is useful as an indication of the 
effect and for the necessity of a repetition of the pro- 
cedure. It is a great mistake to endeavor to lower the 
pyrexia as much as possible. Before the patient is put 
into the bath and after he is taken out it is usual to 
administer a glass of wine, a half ounce of whiskey, a 
half to one drachm of the aromatic spirit of ammonia, 
diluted, or a small cup of hot coffee as the physician 
may direct. During the bath a glass of cold water may 
be allowed. 

The patient's reactive powers may be measured by a 
tentative bath lasting five minutes at 90 reduced to 
8o° F. (32°-27° C.) and the initial temperature, the 
reduction and the length of the following bath may be 
determined accordingly. If possible the physician 
should be present during the bath, both to guard 
against the possibility of shock and to make sure that 
the good effects of the procedure are not lessened by 
too early termination of the bath. 

If the cold tub is not well borne by the patient luke- 
warm baths given in the same manner are often fol- 
lowed by good results. The procedure may bring 
about a drop in temperature of from one to four de- 
grees (F.), but it is wise not to allow a reduction of 
more than two degrees (F.) (one degree C). 



BATHS IN FEVER. 47 

In private practice an ordinary tin bath tub from 
five to six feet long, which may be purchased at the 
plumber's, is convenient. The stationary bath tub, for 
obvious reasons, should never be used. In hospitals 
tubs upon wheels are usually provided. 

Fresh water should be used for every bath. 

The preparation of the bed for the reception of the 
patient is of the utmost importance. All should be 
ready before the beginning of the procedure, so that 
there may be no delay if it become necessary to termi- 
nate the bath sooner than was expected. Two warm 
blankets should be provided and several hot-water bags 
as well, and an ice cap should be ready for the head. 
Over the lower blanket should be placed a warmed 
sheet upon which the patient should be laid on being 
lifted from the tub. The sheet should then be wrapped 
about him and tucked between the arms and the body 
and between the legs, so that no two skin surfaces shall 
come in contact. The patient is thoroughly dried by 
being rubbed outside the sheet. This is then removed 
and he is allowed to lie between the blankets with the 
hot-water bottles at his feet and against his legs and 
the ice cap upon his head. The lowering of the tem- 
perature is not the only good effect produced by this 
measure; it is also a stimulant to the nervous and cir- 
culatory systems. 

2. The Bed or Slush Bath. — This is a less drastic 
method than the tub bath and many patients to whom 



48 FEVER NURSING. 

the cold bath is almost unendurable bear it well and 
are very favorably affected by it. It is given upon a 
bed around the edges of which rolled blankets have been 
placed so as to form a sort of wall. Over this is placed 
a rubber sheet or piece of table oil cloth and into the 
trough thus formed several pails of water are poured. 
The patient is placed in this and treated just as when 
the tub bath is employed. The bed bath may be con- 
structed also by passing a piece of clothes line around 
the head and foot of the bed, connecting these by two 
parallel ropes and throwing over the whole an oil cloth 
which is attached to the rope by clothes pins ; or a rec- 
tangular fence about eight inches in height and slightly 
smaller than the mattress may be constructed over 
which a rubber sheet may be thrown. The water from 
these improvised tubs is best drawn off by a siphon 
made of a few feet of rubber hose. 

3. The Sponge Bath. — For this measure the water 
may be of various temperatures as indicated ; often the 
addition to it of a little alcohol is very grateful to the 
patient. An ice cloth should be applied to the head, a 
sponge or soft cloth is saturated just sufficiently to 
leave a thin film of moisture upon the skin which cools 
the patient by rapid evaporation and does not wet the 
bed clothing, and with this sponge the patient is thor- 
oughly rubbed, while the other hand is performing fric- 
tion, and then dried, one part at a time. Care must be 
taken to keep the portions of the body, not being 



BATHS IN FEVER. 49 

sponged, covered. Particular attention should be given 
the back, for here the tissues retain the heat longest. 
Proper reaction is evidenced by redness of the skin. 
No such effect is produced upon the temperature by 
sponging as by tubbing, nevertheless the fever may be 
slightly lowered. The chief good accomplished is its 
favorable action upon the skin and the great comfort 
which it affords the patient. 

4. The Sprinkle Bath. — As a method for the reduc- 
tion of temperature this may be considered to rival the 
tub bath. It has the advantages of being better borne 
by many patients and of peculiar adaptation to private 
practice. The technique is as follows: The head of 
the bed should be raised about ten inches from the 
floor, and, to keep the mattress from sagging, under it 
should be placed crosswise several pine boards as long 
as the width of the bed. The mattress should be cov- 
ered with a rubber sheet upon which a pillow and ordi- 
nary sheet should be adjusted. The patient should be 
stripped and sprinkled with water of the desired tem- 
perature from an ordinary watering pot or from an 
irrigating apparatus to the tube of which a sprinkling 
nozzle is attached. The water as it flows from the foot 
of the bed should be received in a large dish pan or foot 
bath and can be used over and over, the proper tem- 
perature being maintained by the addition of ice. The 
water should not be poured from too great a height, 
and should be applied chiefly to the abdomen and legs. 



So FEVER NURSING. 

Rubbing with the hands should be kept up throughout 
the procedure and otherwise the patient should be dealt 
with exactly as in tub bathing. 

5. The Sheet Bath. — A sheet wet with water at 
8o° F. (27 C.) is placed upon blankets on a bed or 
table and the patient with arms raised above his head 
is tightly wrapped in it. Water is now poured upon 
the successive parts of the body which are then rubbed 
with the hand until warm and then cooled by means 
of colder water. When an area ceases to become 
warm another part is attacked in like manner, and so 
forth until the whole body has been subjected to the 
procedure. 

6. The Tozvel Bath. — The patient being undressed 
and laid upon a blanket, a thoroughly wet towel is 
placed smoothly over the back; rubbing is employed 
over this until it becomes warm. Then water is poured 
over the surface till it cools, friction is again employed 
and the process repeated till the warmth ceases to re- 
turn. The buttocks are next treated in like manner, 
and the back having been dried, the anterior surface 
receives the same treatment. 

7. The Ice Rub. — This consists simply in rubbing 
the surface of the body with flat pieces of ice covered 
with gauze. The various parts of the body are treated 
one after another until they are cooled. The patient 
is then dried and properly covered. In excessively 



APPLICATION OF COLD IN FEVER. 



5i 



high temperatures the ice rub may be employed while 
the patient is in a tub bath. 

8. The Ice Pack. — The patient being stripped is 
laid upon a bed covered with a rubber sheet. An ice 
cap is applied to his head. Flat pieces of ice are ar- 
ranged along the sides of the body, in the armpits and 
between the legs, and the body is rubbed with pieces of 
ice just as in the ice rub. The ice may be in direct con- 
tact with the skin or wet cloths may be interposed. 

9. Ice Bags, Compresses and Coils. — Ice bags are 
frequently used for the local application of cold. These 
are rubber bags of various shapes and sizes, being 
adapted in these respects to the portions of the body to 
which they are to be applied, and are fitted with screw 
caps. When in use they should be about three quar- 
ters filled with ice broken into pieces the size of the 
end of the thumb. As little air as possible should be 
allowed in the bag. 

Ice compresses are made by crushing the ice and 
spreading a layer of it between two folds of blanket 
or towel, preferably the latter as it will absorb the melt- 
ings while the former will not. These compresses may 
be made of considerable size and applied over large 
areas but their use has the extreme disadvantage that 
it is almost impossible during their employment to 
keep the bed and clothing dry. 

Cold compresses, while they do not affect the bodily 
temperature, often give the patient great comfort espe- 



52 FEVER NURSING. 

cially when applied to local areas of pain. They are 
made of several layers of any cloth which will absorb 
and hold moisture, wrung out of water at the required 
temperature and applied. They may be renewed as 
often as is necessary and it is well to have two in use 
at the same time, or they may be allowed to remain in 
contact with the patient continually, the water lost by 
evaporation being supplied from time to time. 

Ice coils of rubber tubing arranged in various shapes 
to fit the different parts of the body are often used to 
reduce the heat of local inflammation. Water at the 
proper temperature is caused to run through the tubing 
by siphonage, the vessel from which it runs being placed 
above the patient, that into which it is discharged, on 
the floor. Care should be taken that the former does 
not become exhausted. An ice coil may be made at 
home from ordinary flexible rubber tubing about twelve 
yards of which are necessary. Tubing should be coiled 
into circular, oval or rectangular form, depending upon 
the part to which the application is to be made. From 
the beginning and end of the tubing four to six feet 
should be left free and the coil itself be sewed to a 
piece of rubber sheeting. 

10. Ice-water Enemata. — These often cause a con- 
siderable fall in temperature, reaching as they do to the 
" heat-citadel " of the body. Hare has found that 
enemata of 65 ° F. (18.3 C.) lowered the bodily tem- 
perature 3 F. (1.5 C.) in thirty minutes. They 



ICE WATER ENEMATA. 53 

should be given by a fountain syringe, never through a 
Davidson syringe, as the bowel has been ruptured by 
this instrument owing to the sudden increase of pres- 
sure attendant upon squeezing the bulb. The soft- 
rubber rectal tube passed as far as possible into the 
bowel is preferable to the hard-rubber nozzle. The 
usual quantity of water injected is from one to two 
quarts, a return flow being allowed as the fluid 
passes in. 

In using any of the above methods for the reduction 
of temperature the greatest watchfulness of the pa- 
tient's condition should be observed and any tendency 
to collapse as evidenced by distress, weakening of the 
pulse, coldness of the extremities and blueness of the 
lips should cause the nurse to notify the physician 
immediately and to institute prompt restorative meas- 
ures such as the administration of whiskey, brandy or 
the aromatic spirit of ammonia, rubbing the hands and 
feet, hot-water bottles to the extremities and over the 
heart and elevation of the foot of the bed. 

If hyperpyrexia occur in the absence of the physi- 
cian it is the duty of the nurse to meet the emergency 
by the application of cold compresses and by cold 
sponging, in the meantime preparing an ice-water 
enema and cold tub bath pending the arrival of the 
medical attendant. 

The Treatment of Symptoms Referable to the 
Skin. — At the onset of a febrile disease it is often wise 



54 FEVER NURSING. 

to induce free perspiration by the use of hot-water 
bottles, blankets, etc. During the course of the illness 
the patient's skin should be kept clean by a daily bath 
with warm water and soap. Dryness and harshness of 
the skin may be relieved by anointing the body with 
albolene or olive oil. Scales and pieces of epidermis 
that are cast off during and after contagious fevers 
should always be destroyed, preferably by burning, as 
they may become sources of further infection. Special 
attention should be given the points where bed-sores are 
likely to form, namely the backs of the heels and over 
the buttocks and sacrum. The sheets must be kept 
smooth and the bed thoroughly clean and free from 
crumbs, moisture and contamination from the dis- 
charges from the rectum and bladder. The chief con- 
sideration is to prevent the beginning of bed-sores by 
the strictest cleanliness, in addition to which measures 
to improve and harden the skin of the susceptible parts 
should be employed. To insure a good blood supply 
to these parts the patient should be turned upon his side 
several times a day and the skin of the back thoroughly 
rubbed with a dry towel and dusted with talcum 
powder. Applications rubbed into the skin to harden 
it, such as salt two drachms to whiskey one pint or a 
dilute solution of lead subacetate may be employed. 
When the skin becomes red and irritated but is still un- 
broken it should be painted with a solution of silver 
nitrate, twenty grains to one ounce of water. When 



TREATMENT OF FEVER. 55 

a bed-sore has appeared, with the object of preventing 
its spread and of accelerating its cure the patient must 
be so placed as to take all weight from the affected 
part. This may be accomplished by the use of an inflat- 
able rubber bed ring. The sore itself must be kept clean 
by being swabbed with I to 5,000 mercury bichlorid 
solution and dusted with iodoform powder. A dress- 
ing of gauze on which zinc oxid ointment has been 
spread should be applied. In advanced cases the use 
of the water bed may become necessary. If the sore 
spreads and burrows through the surrounding parts 
free opening and thorough irrigation are indicated. 

The Treatment of Symptoms Referable to the 
Mucous Membranes. — Dry and cracked lips may be 
made more comfortable by gentle rubbing with albolene 
or cold cream. For the immediate relief of thirst, 
water, cracked ice and acidulated drinks may be given 
as often as desired ; a drink consisting of glycerin one 
drachm, boric acid half a drachm to the tumblerful of 
water may be found acceptable. The mouth should be 
kept sweet and clean by the employment of regular and 
frequent washings with dilute listerine, tincture of 
myrrh, etc. A very useful formula consists of equal 
parts of listerine, hydrogen peroxid solution, lime water 
and water. The nurse should be careful to see that the 
mouth is washed after each drink of milk. There is no 
counter indication to the use of the tooth brush. Sordes 
and coatings upon the tongue may be removed by swabs 



56 FEVER NURSING. 

moistened in one of the above-mentioned solutions. A 
convenient tongue-scraper may be made of a piece of 
whale bone bent into a loop. In cases where the tongue 
is extremely dry, the " tongue-bath " often affords 
much relief. This consists simply in holding the mouth 
full of fluid for several moments. In this way con- 
siderable moisture is absorbed by the mucous mem- 
branes. 

The Treatment of Symptoms Referable to the 
Digestive Organs. — The nausea and vomiting may be 
relieved by restriction of diet and by the administration 
of cracked ice. All vomited matter should be carefully 
inspected by the nurse and if it is unusual in appearance 
should be kept for examination by the physician. Ex- 
cessive distention of the stomach or bowels by gas may 
be relieved by the application of hot compresses; by 
turpentine stupes which are prepared by wringing out 
a flannel in hot water, sprinkling upon its surface two 
or three teaspoonfuls of turpentine, wringing it again 
and immediately applying it to the abdomen ; if marked 
redness and irritation are caused the stupe should be at 
once removed and the skin anointed with albolene or 
olive oil ; by the insertion of a rectal tube through which 
the gas may be passed; or perhaps best of all by the 
administration of a high rectal irrigation of a warm 
salt solution (one drachm to the pint). 

At the beginning of a fever the bowels should be 
opened by repeated small doses of calomel (one tenth 



TREATMENT OF FEVER. 57 

to one fourth of a grain every half hour to six doses) 
followed by a saline. During the course of the disease 
a daily movement of the bowels should be secured by 
this means, by other laxatives or by enemata of warm 
soapsuds. 

The Treatment of Symptoms Referable to the 
Circulatory System. — The pulse in fever should be 
studiously watched by the nurse and any marked 
change in its character reported at once to the physi- 
cian, since by noting its action a fairly reliable estimate 
of the patient's general condition can usually be made. 
In severe cases heart weakness may call for various 
stimulants such as whiskey. In extreme cases this may 
be administered hypodermatically and in cases of col- 
lapse hypodermatic injections of camphor and ether or 
camphor and olive oil may be given, when directed by 
the physician, with good effect. 

The Treatment of Symptoms Referable to the 
Respiratory System. — The dry, irritating cough 
caused by tickling in the throat may often be relieved 
by a drink of water or milk or by the employment of a 
simple jujube troche or gum drop. Various expecto- 
rant and sedative drugs are used in the cough which 
accompanies involvement of the lungs. If the cough is 
so frequent and severe as to cause soreness of the chest 
this may be lessened by the application of hot com- 
presses or by rubbing with various liniments. 

5 



58 FEVER NURSING. 

The Treatment of Symptoms Referable to the 
Urinary System. — The urine should be carefully ex- 
amined by the nurse as to color and sediment 
and its daily quantity noted; when bidden she 
should save bottled and labeled specimens for the 
physician. Such a specimen to be of any diag- 
nostic value should be a portion of the mixed 
urine of an entire twenty- four hours. Four ounces are, 
as a rule, a sufficient quantity; it is important that the 
bottle should be clean. Freer action of the kidneys 
may be secured and the urine rendered less irritating 
by the administration of a saline diuretic, preferably 
perhaps in the form of " cream of tartar (potassium 
bitartrate) lemonade." This is prepared by dissolving 
one and one half drachms of cream of tartar in a pint 
of boiling water. Allow this to cool and flavor with a 
little lemon juice or peel, add a little ice and sweeten 
with sugar. This is a very palatable drink and may 
be taken ad libitum. When the urine is much dimin- 
ished in quantity, or retention (a rare occurrence) is 
present, an increased flow of urine may be induced by 
hot applications over the kidneys or a high rectal irriga- 
tion of hot salt solution. In certain infectious diseases, 
notably typhoid fever, the urine is capable of trans- 
mitting the infection, consequently it should be handled 
with the greatest care and disinfected properly before 
being disposed of (see p. 85). 



TREATMENT OF FEVER. 59 

Seeming retention of the urine may be treated as 
above. Nervous patients who experience difficulty in 
voiding urine while in the recumbent position may be 
aided in starting the flow by hearing the sound of run- 
ning water or by having warm water poured over the 
pubes. When obstinate retention occurs and the pa- 
tient is entirely unable to void the urine, catheterization 
must be practiced. This may be done by the nurse 
upon the physician's order. Soft-rubber catheters are 
preferable for males and glass instruments for females. 
The greatest care is necessary to keep these absolutely 
clean, for unless this is done infection may be carried 
into the bladder and cystitis result; such an accident 
should never happen and when it does is due to care- 
lessness in the care of the catheters, to lack of cleanli- 
ness of the hands of the person who performs the opera- 
tion or faulty technique in cleansing the patient's ure- 
thral orifice. Catheters should be boiled after using 
and kept in a I to 5000 solution of mercury bichlorid. 
Before passing a catheter the hands should be sterilized, 
the orifice of the urethra cleaned with cotton wet with 
1 to 5000 solution of bichlorid and the instrument lubri- 
cated with sterile albolene or olive oil. It is wise to 
attach about a foot of rubber tubing to the open end 
of the glass catheter so as to guard against its passing 
entirely into the bladder and to lessen the chances of 
soiling the bed clothes with urine. When incontinence 
exists a soft-rubber urinal may be useful. 



60 FEVER NURSING. 

The Treatment of Symptoms Referable to the 
Nervous System. — The discomfort of the initial chill 
of febrile disease may be relieved by warm covering, 
hot-water bottles to the extremities, by rubbing the 
body and limbs with warm woollen cloths and by the 
administration of hot stimulant drinks. These meas- 
ures are also applicable to the relief of chills occurring 
during the course of the disease. In children convul- 
sions may be treated by hot baths — not over 105 ° F. 
(40.5 ° C.)— or by the administration of a few whiffs 
of chloroform from time to time. The passage of a 
stomach tube and the washing out of the organ or a 
rectal irrigation of warm saline solution will frequently 
cause a cessation of the convulsions. 

During convulsions in the course of febrile disease 
the nurse must take care that the patient does himself 
no injury; beyond this the less he is restrained the 
better. Constricting clothing about neck or chest 
should be loosened to guard against interference with 
respiration. If there be movement of the lower jaw 
some object such as a spool or roller bandage should 
be placed between the teeth to prevent biting of the 
tongue. 

The nurse by her manner can do much to lessen the 
irritability and discomfort of ordinary febrile disease. 
She should step quietly, talk little, notice everything and 
while not seeming officious to the least degree, antici- 
pate every wish. 



TREATMENT OF FEVER. 61 

Headache may be lessened by cold or hot com- 
presses to the seat of pain; sometimes the cold will 
prove more efficacious, sometimes the hot; that which 
affords most relief should be selected. 

The pain in the back and limbs may be mitigated by 
hot-water bags, by massage or by rubbing with various 
embrocations. Dizziness is lessened by the recumbent 
position. When arising after a continued illness the 
patient should first be allowed to sit up in bed for an 
hour or two, a day or two later he may be helped to 
an easy chair for a short time, then short excursions 
around the room may be undertaken with the help of 
the nurse, until finally sufficient strength has been re- 
covered so that he is able to walk alone. 

The mental symptoms often are relieved by the use 
of cold as described above ; when they take the form of 
active delirium various sedatives may be administered, 
as the bromids. Chloral, with morphin as a last resort, 
should only be given under the authority of the physi- 
cian. If restraint is necessary, and in extremes of de- 
lirium the strength of several persons may be required 
to hold a vigorous patient, it is legitimate to use a 
folded sheet extending from armpits to groins, laid over 
the patient and fastened under the bed with strong 
safety pins. Restraint by means of tying the hands and 
feet to the bed posts is never necessary. 

During the marked weakness of severe febrile dis- 
eases the patient should not be allowed to move him- 



62 FEVER NURSING. 

self in bed; this must be done for him by the nurse. 
While the patient is in such condition as to be unable 
to make his wants known to the attendants, the greatest 
care must be taken that he receive his nourishment in 
proper quantity and at regular intervals and especial 
watchfulness should be exercised lest the bladder be- 
come too full. Under these circumstances catheteriza- 
tion may become necessary. 

Hiccough occasionally baffles all treatment. Cracked 
ice, a teaspoonful of salt and lemon juice or salt and 
vinegar, or a teaspoonful of raw whiskey may prove 
efficacious. Obstinate cases may respond to the anti- 
spasmodic drugs or the hypodermatic use of morphin 
when ordered by the physician. In certain cases the 
use of electricity may meet with success. 

The Treatment of Symptoms Referable to the 
Organs of Special Sense. — The care of the tongue has 
been described in the section on mucous membranes. 

The Nose. — The dryness and excoriations of the 
nostrils may be prevented by anointing these parts with 
albolene or olive oil and the crusts which collect inside 
the nose may be softened and removed by swabs fash- 
ioned from toothpicks and bits of cotton and dipped in 
any of the alkaline solutions mentioned below. The 
patient should be encouraged to blow his nose and addi- 
tional cleanliness may be secured by the use of the hand- 
bulb atomizer filled with an alkaline spray solution 
such as listerine or glycothymoline diluted one part to 



TREATMENT OF FEVER. 63 

four or six of water. A necessary precaution in this 
process is not to allow the patient to blow his nose for 
some moments after the use of the spray, otherwise bits 
of the secretion may be forced into the eustachian tubes 
and inflammation of these and consequent middle ear 
disease may be caused. 

The Ears. — The increased acuity of hearing which 
may be present in fevers may be rendered less dis- 
tressing by insisting upon quiet in the house and espe- 
cially in the sick-room. A ban should be put upon loud 
conversation, but attendants should converse in a low 
tone, since whispering frequently is extremely irritating 
to the patient. If there be much traffic about the house 
it is often wise to cause the pavements to be strewn with 
tan bark. The patient should be frequently questioned 
as to the presence of pain in the ear and such an occur- 
rence should be immediately reported to the physician. 
Such pain may be relieved by hot applications to the 
organ, by poultices around (never over) it, or by care- 
ful syringing with warm water. It may become neces- 
sary to puncture the drum membrane in order to drain 
the tympanic cavity. This should be done only by the 
physician. When there is discharge from the auditory 
canal cleanliness may be attained by syringing or by 
mopping with small cotton swabs moistened in weak 
antiseptic solution. 

The Eyes. — Increased sensitiveness to light may be 
rendered less annoying by screening the patient's bed. 



64 FEVER NURSING. 

This is preferable to darkening the apartment, for sun- 
light is a sick-room necessity. At night the room 
should be dimly lighted and the lamp so shaded that its 
rays do not fall directly upon the patient. If there is 
tendency to dryness of the eyelids these should be 
moistened with warm boric acid solution (full strength 
or half saturated). When there is tendency to in- 
crease of secretion and the lids stick together the same 
agent may be used or the edges of the lids lightly 
smeared with albolene or olive oil. The eyes should 
not be used during the illness and only to the slightest 
extent during convalescence. This is especially to be 
remembered in the care of cases of measles. 

Feeding in Febrile Disease. — The diet of patients 
suffering from fever must be one consisting of food 
that will be easily digested and at the same time keep 
up the bodily nutrition. All food should be given in 
liquid form and should be of such character as to fur- 
nish as much nourishment for its volume as possible. 

The objects to be attained in the dietetics of fever 
are: 

(a) To supply nutriment sufficient to compensate 
for the tissue consumed. 

(b) To give nourishment which will leave as little 
undigested residue as possible and which will not dis- 
turb the weakened organs of digestion. 

In fevers with remissions of temperature it is best to 
give the largest amount of food while the temperature 



DIET IN FEVER. 65 

is down, for at this time the digestive and assimilative 
powers are best able to do their work. 

Milk, since it offers the greatest amount of nourish- 
ment for its volume, w T ould seem the ideal food but it 
has its disadvantages. Of these the most important is 
that it is likely to coagulate in large curds in the 
stomach, which cause distress and are not easily acted 
upon by the juices of digestion. This fault may be 
obviated in various ways. The milk should be admin- 
istered slowly so that if curds are formed, there will be 
a number of small ones rather than a single large one ; 
by dilution with various carbonated waters or by partial 
predigestion by peptonization (for which peptonizing 
tubes and full directions may be obtained from the 
apothecary) the milk may be so prepared as to avoid 
disturbance from this cause. Kumyss (milk which has 
undergone alcoholic fermentation) or matzoon (milk 
which has undergone lactic acid fermentation) are well 
borne by many patients who object to or are distressed 
by plain milk. 

After milk in nutritive value in fevers come the dif- 
ferent liquid preparations of meat — meat juice, soups, 
broths and the like. Soups and broths contain much 
less nutriment than milk, but on account of the high 
temperature at which they are usually taken and on ac- 
count of the salts which they contain, they possess cer- 
tain stimulant properties w T hich render them useful. 
Patients quickly tire of them, but by flavoring them 



66 FEVER NURSING. 

with the different vegetable extracts, celery, onion, and 
the like, they may be made less monotonous. The 
vegetable purees may be employed. These are pre- 
pared by thickening pure soups with powdered rice, 
arrowroot or flour. 

In mild cases of fever and in those of only short dura- 
tion with little digestive disorder, the patient may be 
allowed the various semi-solid foods such as oatmeal, 
arrowroot or barley gruel, milk toast, meat jelly, soft- 
boiled eggs and the like. 

Many patients insist that they cannot take milk, but 
most of these will find out their error if the nurse will 
exercise tact and gentle persuasion. It may be ren- 
dered palatable in various ways — for instance by the 
addition of half an ounce of strong coffee to each glass, 
or in the form of junket, which may be flavored with a 
little sherry or nutmeg. Matzoon, kumyss and the 
various proprietary foods, malted milk, Mellin's food, 
etc., should be tried if milk really is impossible, and 
if these prove distasteful we must fall back upon the 
soups and gruels above mentioned. A diet of vegetable 
gruels alone will not provide sufficient nourishment, 
consequently these must be supplemented by egg-albu- 
min, gelatin and broths. Eggs may be allowed; these 
are most digestible when raw or only slightly cooked. 
' They may be taken beaten raw with milk, with or with- 
out a little brandy, or the yolk alone may be beaten 
with hot milk or water or with sweetened hot tea. The 



DIET IN FEVER. 67 

eggs should never be boiled, but should be placed in 
water that has been boiling and allowed to stand for a 
quarter of an hour. This process cooks them slightly 
and an egg thus prepared may prove acceptable to 
patients to whom the idea of a raw egg is unpleasant. 

Gelatin in meat, wine or fruit- juice jelly or in the 
form of blanc-mange, which may be variously flavored, 
is often agreeable. These jellies must be given in con- 
nection with other foods, as they contain little nourish- 
ment in proportion to their volume. 

Plain ice creams, preferably flavored with vanilla, are 
allowable. 

Beverages in Febrile Disease. — In all fevers the 
liberal use of water, either plain or flavored with lemon 
juice, is necessary. It not only mitigates the thirst but 
acts as a diuretic and aids in " flushing " the system 
through the kidneys. Patients in the later stages of 
fevers who are unable to ask for it should be regularly 
given water in sufficient quantities by the nurse. 
Lemonade, if preferable to water, should be not too 
sweet and if the patient desires may be made with any 
of the carbonated waters. The juice of squeezed fruit 
strained and either clear or diluted with water is often 
well-borne. It contains some nutriment and is slightly 
laxative. Barley or oatmeal water, plain or sweetened 
and flavored with fruit juices, is often palatable. In 
the milder fevers tea or coffee once a day will do no 



68 FEVER NURSING. 

harm, but when there is difficulty in sleeping, nervous- 
ness or indigestion these should be interdicted. 

The nurse should remember that thirst is much more 
thoroughly assuaged by sipping than by taking con- 
siderable quantities at one time. The patient may be 
allowed to choose the temperature of his beverage, for 
he is much more likely to take the necessary quantity 
of fluid if this privilege be granted. Too much cold 
liquid in the stomach may cause indigestion or cramps, 
but these may be avoided by giving only small quan- 
tities at a time. 

Diet in Convalescence. — Patients who have passed 
through a protracted and severe illness should exercise 
great care in coming back to ordinary diet, for any ali- 
mentary disturbance may cause a rise in temperature 
and other untoward symptoms ; consequently a gradual 
return to solid diet is advisable. 

Often the first solid food allowed is a sandwich of 
dry toast or zwieback and scraped beef or minced 
chicken ; later the variety may be increased by the addi- 
tion of soups thickened with rice, barley, plasmon, ver- 
micelli or noodles. The various cereals, plain custards 
and stewed fruits may be added in quick succession. 

Below is given a diet list for convalescents from ordi- 
nary febrile diseases. Such a list must be greatly modi- 
fied for typhoid fever patients or those who have suf- 
fered from other fevers which especially affect the 
digestive system. 



DIET IN FEVER. 69 

First Day. 
Breakfast. — Soft-boiled egg, zwieback, cocoa. 
Luncheon. — Egg-nog. 

Dinner. — Bit of breast of chicken, slice of dry toast. 
Luncheon. — Cup of hot bouillon. 
Supper. — Scraped beef sandwich, lemon jelly, glass 
of milk. 

Second Day. 

Breakfast. — Poached egg on toast, cocoa. 
Luncheon. — Cup of junket. 

Dinner. — Puree of potato soup, crackers or zwie- 
back, rice pudding with cream. 
Luncheon. — Milk punch. 
Supper. — Milk toast, wine jelly, cup of tea. 

Third Day. 

Breakfast. — Egg omelette, roll, coffee with cream 
and sugar. 

Luncheon. — Hot beef broth. 

Dinner. — Lamb broth with rice, bread and butter, a 
little vanilla ice cream. 

Luncheon. — Cup custard. 

Supper. — Half dozen raw oysters, crackers, junket, 
cup of tea. 

Fourth Day. 

Breakfast. — Baked apple with cream, oatmeal or 
other cereal with cream and sugar, soft egg, dry toast, 
coffee. 

Luncheon. — Chicken broth. 



7o FEVER NURSING. 

Dinner. — Puree of celery soup, crackers, broiled 
lamb chop, mashed potato, wine jelly. 
Luncheon. — Cup of junket. 
Supper. — Scrambled eggs, dry toast. 

Fifth Day. 

Breakfast. — Orange, cereal with cream and sugar, 
coffee or cocoa, roll and butter, poached tgg on toast. 

Dinner. — Half dozen raw oysters, consomme with 
vermicelli, small piece of tenderloin steak, creamed po- 
tatoes, vanilla ice cream or lemon ice. 

Supper. — Creamed toast, baked apple with cream, 
cup of tea. 



CHAPTER IV. 

FEVER (Continued). 

The Nurse: The Sick-room and its Furniture: The Patient: 
Quarantine : Disinfection. 

The Nurse should go to her patient provided with 
her usual outfit, a description of which is unnecessary; 
she should be cleanly in person and attire, observant 
and tactful. She should not, under any circumstances, 
converse, with either the patient or members of his 
family, upon other cases of like disease which she has 
cared for and, above all, she should not, no matter what 
she may think, criticize the attending physician's admin- 
istration of the case. 

The Sick-room. — The apartment used by a person 
ill with febrile disease should be, if possible, at the top 
of the house, for the air here is purer than that nearer 
the ground. Since it is to be occupied during the term 
of illness by at least two persons, the patient and the 
nurse or nurses, it should be large. Every adult re- 
quires at least three thousand cubic feet per hour of 
fresh air, and this will necessitate a room the capacity 
of which is about six thousand feet. Such an apart- 
ment is approximately fourteen feet square by eleven 
feet high, or of such proportions that its cubic content 

7i 



72 FEVER NURSING. 

is that of a room of these dimensions. A room of this 
size does not allow space for large pieces of furniture, 
and if it is to contain such its measurements must be 
correspondingly larger. Sufficient number of windows 
is necessary to insure plenty of light and proper venti- 
lation, for while fever patients are more sensitive to 
sudden draughts than persons in health, fresh air is an 
all-important consideration. Too bright light in a 
sick-room is to be avoided, nevertheless the apartment 
should be kept cheery rather than gloomy. It will sel- 
dom be found necessary to darken the apartment ex- 
cept in cases involving brain or eye complications. 
Proper shades for the windows will, when carefully 
disposed, be found to admit a sufficient degree of light. 
Ventilation in a private dwelling is usually provided by 
doors, windows and fireplaces, mechanical ventilation 
being seldom found in any except public buildings. 
Having recourse to these three means of ventilating the 
sick-room, we must contrive to arrange for sufficient 
change of air to afford proper ventilation without 
allowing draughts. The fireplace offers a fair outlet 
to vitiated air but its chief fault is that its opening is 
near the floor while impure air seeks the upper levels 
of the room atmosphere. An occasional fire built upon 
the hearth will increase the usefulness of this means of 
ventilation. Various appliances may be used to render 
the windows better ways of egress for impure air and of 
ingress for pure. One of the best of these is a piece of 



THE SICK ROOM. 73 

board four or five inches wide and as long as the width 
of the window-frame in which it is to be used. The 
window should be lowered from the top just far enough 
to admit the board which is placed in position, then 
between the upper and lower sashes there is a narrow 
space through which outside air may enter. Through 
the board may be bored holes of various number, de- 
pending upon the temperature outside, through which 
the air of the room may make its exit. In cold weather, 
or when the outside air is smoky or dusty, the opening 
between the two sashes may be packed with varying 
degrees of tightness with cotton. The temperature of 
the room should be from 65 to 70 F. (i8.4°-2i.i° 
C.) in cold weather and in summer as near this tem- 
perature as is practicable. In hot weather the blinds 
and windows should be kept partly closed during the 
day and opened at night. An electric fan may add to 
the thoroughness of the ventilation and to the patient's 
comfort. 

There should be no hangings, pictures or carpets, 
and as little furniture as possible in the ideal sick 
chamber; this must be insisted upon in cases of con- 
tagious disease. If there be a set wash bowl in the 
apartment it is well to keep its outlet plugged lest im- 
pure air enter through a possibly defective trap. The 
floors and walls should be bare and smooth so that they 
may be easily cleaned and washed with disinfectants if 
6 



74 FEVER NURSING. 

necessary. Adjoining the sick-room there should be 
a bath-room, with tub, wash-bowl and water closet. 
All creaking doors and blinds should be oiled. The 
patient's apartment should be kept as fresh and cheery 
as possible, and cleanliness must be attained by daily 
mopping the floor with a mop dampened with a dis- 
infecting solution (i to 1,000 mercury bichlorid) and 
by wiping walls, wood work and furniture with cloths 
dampened in the same medium. If sweeping is abso- 
lutely necessary the floor should first be dampened. 
Dry sweeping and dusting are to be absolutely for- 
bidden. 

Unpleasant odors may be dispelled by sprays of 
Labarraque's solution or of cologne water unless dis- 
agreeable to the patient. Fresh flowers may be allowed 
in the room but upon leaving it should be burned. 

A roomy closet is a convenient and almost necessary 
adjunct; in it may be kept various unsightly utensils, 
medicine bottles, disinfecting solutions and the like, and 
in non-contagious cases, bed-linen, towels, etc. 

During the day the room may be kept as bright as 
the patient wishes. Should he prefer a dim light this 
may be provided for by shading the windows and 
screening the bed. At night the lamp should be low 
and so disposed that its rays do not fall directly upon 
the patient. 

The Furniture. — The bedstead preferably should be 
of metal of plain design and furnished with a stiff wire 



THE FURNITURE. 75 

mattress. The single bed is better than the double 
since it permits the nurse to handle the patient with 
far greater ease. The iron hospital bedstead which 
stands about six or eight inches higher from the floor 
than the common article is much the most convenient. 
Four wooden blocks each with a depression in its top, 
into which the casters fit can be used to increase the 
height of an ordinary bedstead. The location of the 
bed should be such as to provide easy access to each 
side, out of the passage of draughts and not in too 
bright light. 

The mattress should be thin and stuffed with hair. 
In some hospitals instead of a mattress a number of 
blankets folded to the proper shape and size and placed 
directly upon the springs are used. These make an 
excellent and comfortable bed, the great advantage of 
which is ease of disinfection. 

The sheets should be of cotton rather than of linen 
and beneath the drawsheet a piece of rubber or oil- 
cloth, to protect the mattress from discharges, should 
be placed. Folded newspapers will answer this pur- 
pose in an emergency. 

Woolen blankets afford the best bed covering, being 
warmer for their weight and more easily disinfected 
than any other. 

The other pieces of furniture of the room should be 
of plainest design and as few in number as possible. 
Two chairs, one of them a steamer chair perhaps, but 



76 FEVER NURSING. 

neither of them rockers and both with as little uphol- 
stery as possible, and two or three small tables, one of 
them a bed table (a table with its point of support at 
one side so that its top can be placed over the bed) a 
commode, a screen and a back rest, should be sufficient. 

The Patient should wear a night shirt open entirely 
down the front to facilitate changing and physical ex- 
aminations by the physician. In the case of women the 
hair should be neatly braided, or if considered neces- 
sary, it may be cropped. Severe febrile disease may be 
followed by loss of the hair; fortunately such a loss is 
rarely permanent. 

The nurse should assist the patient at his toilet morn- 
ing and evening; his face and hands should be gently 
bathed with wash cloth or cotton, soap and warm 
water, the mouth should be rinsed and when desirable, 
the teeth may be brushed. The hair should be neatly 
and freshly arranged, and shaving, with the permission 
of the physician, may be permitted. The patient should 
be given a general cleansing bath with soap and warm 
water each day, and frequently his comfort may be 
greatly increased by an alcohol rub. If he is allowed 
to rise for urination and defecation he should be 
wrapped in a flannel dressing-gown and assisted to the 
commode which must be placed near the bed. In 
severe cases it is always desirable that the bed pan be 
used. Although some patients will insist upon their 
inability to use this vessel, a little tactful persuasion will 



CARE OF THE PATIENT. 77 

generally convince them of their error. Should any 
accident befall during its use or that of the urinal the 
soiled linen should be at once removed and the skin 
cleansed. 

Visitors to patients ill with febrile diseases should 
be few and it is better to permit none at all until the 
period of convalescence has begun. The fewer the 
visitors allowed the less will the patient be distracted 
and excited, for even if visits please him their ultimate 
effect is untoward. If no visitors are allowed then 
there is no danger of their contracting or transmitting 
the disease if it prove contagious. In cases of recog- 
nized contagious disease visitors must be absolutely 
interdicted. If the physician, as is his right and oft- 
times his duty, forbid all visitors, even members of the 
family, entrance into the patient's presence, then the 
nurse can enforce the orders without causing hard- 
feeling toward herself. 

The nurse should perform her various duties quietly 
and regularly, and in particular, all duties directly 
affecting the patient should be transacted, if possible, 
at the same time every day; making the bed and the 
patient's toilet, and especially administering his food, 
should be done according to schedule. 

Usually the physician will call at about the same time 
each day and, when method is the watchword of the 
sick-room, the nurse will always be prepared for his 
entrance either at the regular hour or at any other. 



7^ FEVER NURSING. 

Nothing is more disturbing to the entire scheme of 
sick-room administration than a visit from the med- 
ical attendant when the nurse is unprepared for the 
event. The nurse should rise at his entrance, if not 
already standing, and accompany him in his inspection 
of the apartment and patient. She should maintain a 
discreet silence, speaking only in response to questions. 
At the close of the visit, if there be anything not down 
upon the chart which she wishes to report or any point 
which she wishes elucidated she may make the report 
or the necessary inquiries. She must note the physi- 
cian's orders upon a bit of paper; on no account may 
she trust to memory for them. After his departure 
these should be put among the charts and records of the 
case wherein are noted the patient's temperature, pulse 
and respiration ; number and character of stools ; quan- 
tity of urine ; time, quantity and character of feeding ; 
medication, etc. 

No single nurse is able to care for a severe case, nor 
can she be expected to do night and day duty in a 
light case; in the former contingency a second nurse 
is necessary and in the latter, a member of the family 
or a servant must give assistance. 

In all severe cases a night as well as a day nurse is 
required, each caring for the patient for twelve of the 
twenty-four hours. Seven o'clock in the morning and 
seven in the evening are convenient hours for changing. 



DISINFECTION. 79 

The nurse's meals should not be served in the sick- 
room for obvious reasons. 

Disinfection During and After Febrile Diseases. 
— Since it is of the most paramount importance in the 
prevention of the spread of infectious fevers that all 
contaminated material should be properly treated and 
proper disinfection carried out when the case is finished 
and since upon the nurse the duty of seeing that this is 
accomplished frequently devolves, it is necessary that 
she should be thoroughly conversant with the means 
and methods to these ends. 

In considering this subject it is well that a clear 
knowledge of the term " disinfectant " be insisted 
upon; since so many substances are sold under this 
name that are far from being what they purport to be, 
it is necessary that the term should be strictly definite 
and that only such substances be used in this important 
connection as are of known composition and efficacy. 

All authorities are agreed that a true disinfectant is 
a substance which destroys all infectious organisms 
with which it comes in direct contact, while an anti- 
septic is one which merely checks the growth and 
multiplication of such germs, not, of necessity, destroy- 
ing them; and that a deodorant is a substance which 
merely neutralizes offensive odors, acting as a germi- 
cide or not, as the case may be. 

Steam under pressure is the most certain disinfectant 
and the only one upon which we can safely rely in the 



80 FEVER NURSING. 

disinfection of clothing, bedding and the like. Sulphur 
dioxid gas is an effective germicide and it may be pro- 
duced by burning the ordinary rolled sulphur, which is 
cheap and easily obtainable, or the sulphur candles 
specially prepared for disinfecting purposes. It must 
be remembered that sulphur dioxid gas bleaches and is 
otherwise injurious to delicate fabrics, and gilded arti- 
cles, such as picture frames. 

Formaldehyde gas is an efficient disinfectant and is 
free from certain disadvantages which sulphur dioxid 
possesses, in that it does not affect fabrics and decora- 
tions to any appreciable extent. Tablets may be pur- 
chased of the apothecary, which, when burned in a 
specially constructed lamp, generate this gas. They 
are inexpensive and easily manipulated but give off the 
gas so slowly that an apparatus which produces the gas 
rapidly and forces it into the apartment is far prefer- 
able. Such an apparatus is, unfortunately, complicated 
and expensive, but if available provides, perhaps, the 
best method of securing disinfection by formaldehyde. 

It is absolutely necessary that disinfection of apart- 
ments be carried out in the absence of human beings, 
for it is quite impossible for respiration to be sustained 
in such an atmosphere as is requisite for the destruction 
of germ life. All attempts at disinfection during the 
patient's illness by means of placing vessels containing 
carbolic acid about the room, by burning bits of sulphur 
or by spraying disinfectants into the air are worse than 



DISINFECTION. 81 

futile since they make the patient uncomfortable. Good 
ventilation will accomplish far more as regards disin- 
fection than all these means combined. 

Before leaving the sick-room, a patient who has had 
an infectious fever should be given a thorough bath and 
shampoo with soap and hot water and then be sponged 
off with a i to 3,000 solution of mercury bichlorid or 
immersed in a 1 to 5,000 solution of bichlorid bath. 
He then should be dressed in a clean night dress and 
removed to another apartment where he may put on 
other clothing. 

The disinfection of the sick-room and its contents 
depends largely upon the means at the disposal of the 
physician and nurse. If a steam disinfecting plant is 
at hand the bedding, draperies and other fabrics should 
be made into bundles, wrapped in clean sheets and re- 
moved for steam disinfection. By carefully carrying 
such bundles, they may be transferred to the disinfect- 
ing station with little danger. The bedstead, furniture 
and woodwork must be carefully washed with a soft 
cloth wet with 1 to 1,000 bichlorid solution or 3% car- 
bolic acid. All cracks and crevices must receive studi- 
ous attention. The removal of all unnecessary articles 
at the beginning of the disease greatly simplifies the 
disinfecting process. The walls, if painted, should be 
treated in the same manner as the wood work ; if they 
are papered they should be thoroughly rubbed with 



82 FEVER NURSING. 

pieces of bread, then, if practicable, the old paper 
should be removed and the walls repapered. 

After these details have been attended to all the win- 
dows and the doors, with one exception, should be 
closed and sealed by pasting strips of paper with com- 
mon flour paste over all the cracks. The sealing 
process is important, for upon the tightness of the room 
depends, in great measure, the efficacy of the disin- 
fection. If the cracks allow the escape of the disinfect- 
ing gas, the process is of little value. Before sealing 
the last door all draperies which have not been removed 
must be spread out and all drawers, closet doors, etc., 
widely opened. 

Sulphur dioxid or formaldehyde gas may be used to 
disinfect the room. If the apartment is bare and con- 
tains little decoration the former may be employed; if 
the reverse is the case the latter is to be preferred. If 
sulphur disinfection is chosen, four pounds must be 
used for each 1,000 cubic feet of room space. A simple 
method of generating the gas may be arranged as fol- 
lows: Two or three bricks are laid upon the bottom 
of an ordinary wash tub and upon these is placed a 
dish-pan or other metal receptacle which is to hold the 
sulphur. The tub should contain enough water to 
cover the bricks and the bottom of the pan, so that 
there shall be no danger of fire. For this reason the 
vessel which holds the sulphur must never be placed 
upon the floor. The sulphur is to be broken in small 



DISINFECTION. 83 

pieces, over which alcohol is poured and set on fire by 
touching a match to the mixture. The operator should 
stand at as great a distance as possible while applying 
the match. If enough alcohol is used the sulphur will 
be almost entirely consumed, and it is important that 
the pan should not contain too much sulphur, as in 
this case the combustion will not be complete. On this 
account it is better to use two or more pans for the 
sulphur if the room is large. To produce proper dis- 
infection it is necessary that moisture be present, and to 
provide for this, unless the weather is damp, we must 
supply this lack. This may be done by boiling water 
over a gas stove or by pouring boiling water from one 
vessel into another in the room just before the disin- 
fection is begun. Another method is to place a vessel 
of water a few inches above the burning sulphur. The 
sulphur should always be prepared so that it may be at 
once set on fire after the moisture has been supplied. 
After lighting the sulphur the room should be imme- 
diately closed and the door of exit sealed as described 
above. 

If formaldehyde gas is employed it may be gener- 
ated from the tablets mentioned in a preceding para- 
graph or generated from formalin in an apparatus 
which sends the gas rapidly through a tube passed 
into the keyhole of a door. The latter method is pre- 
ferable but less practicable than the former. 



84 FEVER NURSING. 

Whichever method is chosen the room should remain 
sealed for at least eight hours. Even at the end of this 
time great care must be exercised in entering the apart- 
ment, and in so doing it is wise to wrap the face in a 
wet towel, pass quickly to a window and open it to 
allow the gas to escape and the fresh air to enter. 

Disinfection of Excreta, etc. — During the illness 
all feces, urine, pus from abscesses and all other dis- 
charges should be so disposed of that any infective 
material that they may contain shall be rendered harm- 
less. All substances cast off from the body should be 
received into glass or porcelain vessels containing a 
considerable quantity of disinfectant. The following 
are solutions adapted to this purpose: 

1. I to 1,000 mercury bichlorid solution. 

2. 5% carbolic acid solution. 

3. Calcium chlorid four ounces to one gallon of 
water. This last must be prepared freshly every day. 

The ordinary disinfection of feces in the sick-room 
by nurse or attendant is of little value. This is due to 
the facts that the solution is seldom of sufficient 
strength and that the fecal matter is not thoroughly 
mixed with the disinfectant. The feces must be care- 
fully macerated so that the disinfectant shall come in 
contact with every atom and the mixture must be 
allowed to stand for several hours. It may then be 
disposed of through the water closet or buried. Bury- 
ing undisinfected stools cannot be too strongly con- 



DISINFECTION. 85 

demned and is a serious menace to the public health. 

The urine should be mixed with at least one tenth of 
its volume of 1 to 1,000 bichlorid solution and allowed 
to stand for ten minutes before being thrown out. 

Sputum should be expectorated into vessels contain- 
ing 1 to 10 carbolic acid solution or the lime solution 
given above. Remnants of food should be disin- 
fected in like manner. Pus dressings, etc., should be 
burned. 

All bed-linen and clothing should be immersed in 1 
to 1,000 bichlorid solution or three per cent, carbolic 
acid immediately upon removal and allowed to stand 
for at least two hours before being sent to the laundry. 

It is advisable for the nurse to make a stock solution 
of twenty-five per cent, bichlorid, bottle and label it 
with a table giving the proportion to be added to water 
to make solutions of various strengths. From this 
stock bottle solutions may be prepared as needed. This 
obviates waste of time in dissolving tablets and is very 
economical. 

The surface of the patient's body and that of the 
attendant when soiled with discharges should at once 
be washed with a suitable disinfecting agent (1 to 5.000 
bichlorid) . In diseases like small-pox and scarlet fever 
sponging the patient's body once a day with this solu- 
tion is to be advised. 

The nurse should always change her clothing and 
sterilize her hands before eating. The latter may be 



86 FEVER NURSING. 

done by thorough washing with soap, hot water, brush 
and I to 5,000 bichlorid. 

After death from an infectious disease the body- 
should be sponged with bichlorid or carbolic solution, 
the mouth, nostrils and anus plugged with pledgets of 
cotton moistened with either of these, wrapped in a 
sheet saturated with a disinfectant, placed in a metallic 
or air-tight coffin and buried as soon as possible. The 
disposal of such bodies by cremation is always to be 
preferred when practicable. 

The Disinfection of Water-closets, Drains, Sinks 
and Privies. — In the disinfection of these nothing is 
more convenient and effective than lime chlorid, which 
is a mixture of various chlorin compounds, or milk of 
lime freely used ; the latter is made by adding one pound 
of freshly slaked lime to two or three quarts of water. 
Lime chlorid should be purchased in sealed packages 
only, otherwise its efficacy as a disinfectant is slight. 
Air-slaked lime is of no use as a disinfecting agent. 

The fecal discharges from patients suffering from 
dysentery, cholera or typhoid fever should never be 
finally disposed of without previous disinfection as de- 
scribed above. All sinks, drains, water-closets, etc., 
should be thoroughly flushed several times daily and in 
the intervals of flushing chlorid or milk of lime should 
be allowed to remain in them. The seats of commodes 
and water-closets must be immediately cleaned, with 
a disinfectant, of any discharges which may soil them. 



CHAPTER V. 

INFECTIONS OF CONTINUED TYPE. 

Enteric Fever: Paratyphoid Fever: Weil's Disease: Typhus 
Fever: Yellow Fever: Influenza: Malta Fever: Mountain 
Fever: Acute Miliary Tuberculosis: Chronic Pulmonary 
Tuberculosis. 

Enteric Fever. 

Synonyms. — Typhoid fever; nervous fever; abdomi- 
nal typhus. 

Definition. — A communicable fever lasting three 
to four weeks, marked by inflammation and ulceration 
of certain glands in the intestine, catarrhal inflammation 
of the mucous membrane lining the intestine, enlarge- 
ment of the mesenteric lymph glands and the spleen and 
an eruption of small rose-colored spots appearing in 
crops upon the chest, abdomen and flanks. 

Causation. — The disease is both endemic and epi- 
demic and is found in all climates, although its severity 
may vary greatly in different places. It is more com- 
mon in the Eastern and Middle States than farther 
west and is continuously found in the larger cities, in 
which there are a certain number of cases to be found 
at all times. The most favorable time for the disease 
is the late summer and early autumn, and it is more 

87 



SS FEVER NURSING. 

prevalent and severe in dry than in wet seasons. 
Young adults (15 to 35 years) are more susceptible 
than are children and old persons. When there is no 
difference in the exposure the infection is equally fre- 
quent in males and in females. As is the case with all 
infectious fevers not all exposed persons acquire the 
disease. Those whose condition is below par are more 
likely to suffer from it than those in robust health, 
and some individuals seem to be more susceptible to the 
infection than others. One who has once had the dis- 
ease seldom suffers from a second attack. 

The actual cause of the disease is the bacillus 
typhosus which was first described by Eberth in 1880. 
The bacillus gains entrance to the body usually through 
the alimentary tract, but may be breathed in with air 
contaminated by the dust of dried undisinfected stools. 
The germ is not destroyed by drying and may live for 
months in the soil and upon clothing. It is not ren- 
dered harmless by freezing and therefore the disease 
may be conveyed by ice. It may be taken into the 
body with water contaminated by sewage, milk from 
vessels washed with infected water, upon vegetables 
which have been fertilized with sewage, oysters from 
beds near sewer exits and flies may transmit the con- 
tagion by alighting upon food after having been in- 
fected from privies. 

Nurses may infect their hands from stools, bath 
water, thermometers, etc., and laundresses who wash 



ENTERIC FEVER. 89 

undisinfected clothing also may convey the bacilli to 
their mouths while eating with infected hands. Bath 
water splashed into the mouths of attendants may also 
transmit the disease. Many persons who drink the 
various bottled spring waters hoping to avoid the dis- 
ease forget that the ice used may be contaminated and 
that infected water used in brushing the teeth is as dan- 
gerous as when drunk; consequently the nurse should 
cool all mineral waters, etc., by placing the bottles upon 
ice rather than by mixing cracked ice with them. 

The bacillus may be found in the feces within five to 
ten days after the disease has begun and it may remain 
in them through the convalescence, but usually it dis- 
appears within about ten days after the fall of the tem- 
perature to normal. 

The urine contains the typhoid germ in a consider- 
able number of cases, but as a rule not until late in the 
disease. The organism often persists in the urine for 
some weeks after the patient has apparently recovered. 
It may also be found in the blood, the perspiration, the 
rose spots, the intestinal ulcers, and in the pus from 
abscesses which often complicate the disease, and it is 
probable that it exists in the expired air and in the 
sputum of cases complicated by bronchitis or pneu- 
monia. 

The Onset of the Disease. — Usually typhoid fever 
develops gradually and the patient may be quite unable 
7 



9° FEVER NURSING. 

to fix definitely the first day of his disease. In ordinary 
cases the day upon which he went to bed is considered 
as the first day, but in hospital cases and many 
others the use of such a rule as a routine will give rise 
to many errors. 

The usual mode of onset is as follows : The pa- 
tient notices slight chilly feelings, followed by feverish 
sensations, severe headache, nausea, vomiting and con- 
siderable prostration. Nose-bleed and cough are fre- 
quent early symptoms. Various unusual modes of 
onset may occur: 

(a) Ambulatory or Walking Typhoid. — In this 
variety the patient keeps up and about and attempts 
to work. He realizes that he is not perfectly well but 
feels hardly ill enough to go to bed. When he is first 
seen by the physician he may have a high fever and a 
well-developed rash. Such cases are likely to prove 
severe because of the lack of proper care in the early- 
stages. 

(b) With Marked Gastrointestinal Symptoms. — 
The nausea may be severe and the vomiting almost 
continuous and very difficult of control. There may 
be profuse diarrhea. 

(c) With Intense Pulmonary Symptoms. — The 
usual cough accompanying the onset may be much 
accentuated and the chill and pain in the side be of 
such character as to strongly suggest pneumonia. 



ENTERIC FEVER. 9 1 

(d) With Symptoms Referable to the Kidneys, — 
Dark or bloody urine containing albumin and casts may 
exceptionally be a feature of the onset. 

(e) With Pronounced Nervous Symptoms. — Agon- 
izing and obstinate headache or facial neuralgia may be 
initiar symptoms. In some cases when the patient has 
kept about during the early weeks delirium may be 
the first symptom to appear. Rarely the disease may 
begin with twitchings of the muscles or convulsions, 
stiffness of the neck and dread of bright light. Drowsi- 
ness, apathy and stupor may exist for some days before 
other and more typical symptoms develop. Infre- 
quently mania may be the first symptom. In alcoholic 
patients the various nervous manifestations are espe- 
cially marked. 

(f) Hemorrhage from the Intestine or Perforation 
of the Bowel are very rare symptoms of onset. 

The Course of the Disease. — The incubation 
period is from ten to twenty days, usually about two 
weeks, and the ordinary duration of the disease is four 
weeks; to each week belong certain symptoms. 

The typical temperature of typhoid fever is as fol- 
lows : During the first week the temperature rises regu- 
larly each day, being lower in the morning than in the 
evening, but day by day the difference between these 
temperatures becomes less.. The temperature the sec- 
ond week is continuously high and there is little dif- 
ference between that of the morning and that of the 



9 2 FEVER NURSING. 

evening. In the third week the morning temperature 
becomes lower while that of the evening remains as 
high as during the second week. The typical fourth- 
week temperature is one in which the morning tem- 
perature falls gradually lower and that of the evening 
does likewise, dropping a little lower each day, until 
both it and the morning temperature reach normal. 
On the opposite page is depicted the chart of a typical 
case of typhoid fever in which the temperature has 
been uninfluenced by antipyretic drugs or baths. 

Complications may alter the course of the tempera- 
ture. Intestinal hemorrhage and perforation are 
usually followed by a rapid and considerable fall. In 
fatal cases the temperature is likely to continue high 
until death. The height of the fever is, as a rule, in 
direct proportion to the severity of the disease but in 
some fatal cases the temperature may never reach a 
very high level. 

The pulse usually bears a direct relation to the tem- 
perature curve. In the first week it is full, strong and 
of 90 to 100 beats to the minute, during the second and 
third weeks it is likely to become more rapid, feeble 
and perhaps dicrotic. 

Various deviations from the typical temperature 
curve are frequent. When the disease begins with a 
chill the fever may rise at once to 103 F. (39.5 C.) 
or 104 F. (40 C). Often defervescence takes place 
at the end of the second week and the temperature may 



ENTERIC FEVER. 



93 



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94 FEVER NURSING. 

fall to normal within twenty-four hours. A tempera- 
ture higher in the morning and lower in the evening 
may occur but has no particular significance. Sudden 
falls of temperature may take place and usually indi- 
cate intestinal hemorrhage or perforation. Hyperpy- 
rexia (temperature above 106 F. — 41. i° C.) is rare 
but may occur just before death. 

There may be chills at the beginning of the disease ; 
at intervals during its course; with the onset of com- 
plications ; after the use of antipyretic drugs ; and dur- 
ing convalescence without assignable cause. 

Sweats may accompany the chills but profuse per- 
spiration is rare though the abdomen and chest may at 
times be moist, especially during the reaction from a 
bath. 

Rises of Temperature After Defervescence {Re- 
crudescences) may take place even after there has been 
no fever for several days. Such rises may last for a 
number of days and then disappear. With these there 
is no constitutional disturbance but they are, neverthe- 
less, causes of anxiety. These are usually due to im- 
proper feeding, constipation or unwonted mental ex- 
ertion. 

There are cases in which convalescence has appar- 
ently become established but which continue to have an 
evening rise of temperature of one or two degrees 
(F.). This may be due to starvation but cause one 
to search for complications. In excessively nervous 



ENTERIC FEVER. 95 

patients such an evening rise is a frequent occurrence, 
but if the patient show no other symptoms, it may be 
disregarded. It often disappears if the patient be 
allowed to sit up and be given solid food in small quan- 
tity and the use of the thermometer be discontinued. 

Relapses are due to a fresh infection and may last 
varying lengths of time, but as a rule they are shorter 
than the original fever. The temperature rises and 
declines gradually and is accompanied by a return of 
the symptoms. 

Afebrile Typhoid (typhoid fever without rise of tem- 
perature) has been observed, but is of very rare occur- 
rence. 

Symptoms — The Facial Appearance. — Early in the 
disease the face is flushed and the eyes are bright; by 
the beginning of the second week the expression be- 
comes apathetic and at the height of the infection it is 
dull and listless. The lips and cheeks may retain a 
good color throughout the disease. 

The Skin is usually dry. The typical eruption of 
typhoid fever appears in crops from the fifth to the 
twelfth day of the disease and consists of small, 
isolated, rose-colored, slightly elevated round or oval 
spots of about the diameter of a pinhead (2 to 4 milli- 
meters). They disappear on pressure but immediately 
reappear when pressure is removed. They are seen 
earliest upon the back, and slightly later upon the front 
of the chest and abdomen. They may be found upon 



96 FEVER NURSING. 

the arms and thighs but very rarely upon the forearms 
and lower legs. They appear in successive crops, each 
crop lasting two to four days, while the eruptive period 
lasts from two to twenty-one days. Relapses show a 
fresh eruption and the spots may appear after the 
establishment of convalescence. Some cases show no 
eruption whatever. 

The Typhoid Tongue is at first moist and down its 
center is a strip of whitish fur; its edges and tip are 
red. In mild cases the tongue continues moist through- 
out the disease, but in severe cases it becomes dry, 
brown and cracked. Rarely it may remain clean but 
become dry, glazed and fissured in the later weeks. 
As convalescence progresses the tongue gradually re- 
assumes its normal appearance. 

A Typical Case of Enteric Fever. — During the 
period of incubation of from ten to twenty-one days the 
patient suffers from indefinite feelings of languor and 
is disinclined toward exertion of any sort. He lacks 
energy and may complain of general muscular sore- 
ness. 

First Week. — At the invasion of the disease there 
are indistinct chilly feelings (rarely a distinct chill), 
severe frontal headache and pains in the back and 
limbs; the tongue is coated down its center, its edges 
and tip are redder and the papillae more prominent than 
usual. There may be spontaneous nose-bleed and there 
is often cough due to slight laryngitis or bronchitis. 



ENTERIC FEVER. 97 

The eyes are suffused. The patient feels feverish, is 
thirsty and complains of weariness, sleeplessness and 
nausea which is often accompanied by vomiting. Con- 
stipation is the rule, but there may be diarrhea. There 
may be sore-throat with pain on swallowing. 

Patients during this stage of the disease may con- 
tinue up and about (walking typhoid), but usually they 
find that they are more comfortable in bed. The tem- 
perature of the first week has been described. By the 
fifth or sixth day it reaches an evening height of 103 
to 103.5 F. (39.5 to 39.8 C). The pulse is rapid, 
strong and bounding, 90 to 100 per minute and very 
rarely may be dicrotic. By the end of the week the 
typical facies of the disease appears and the expression 
is dull and lethargic. A few spots may have shown 
themselves and the spleen may be palpable. 

Second Week. — As the second week progresses all 
the symptoms become accentuated with the exception 
of the headache, nausea and vomiting. These usually 
cease. The temperature continues high ( 103.5 ° t° 
104 F. — 39.8 to 40 C.) with slight morning remis- 
sions. The pulse becomes softer, feebler and more 
rapid (100 to 120). Bodily weakness is pronounced 
and the patient has no desire to move. Early in the 
week the rash becomes evident. The tongue is dry, 
brown and tremulous ; there is likely to be diarrhea, 
three to five thin pale yellowish-brown stools a day 
(pea-soup stools). Mild delirium may appear late in 



98 FEVER NURSING. 

this week ; at first it may be present only at night, later 
it lasts through the day as well and the patient shows 
other signs of great nervous weakness, such as avoid- 
ance of light, slight deafness and twitching of the mus- 
cles. If there is no delirium the patient is very stupid, 
takes no interest in his surroundings and makes no 
requests. 

Third Week. — The symptoms of the second week 
continue and become more pronounced. The tempera- 
ture continues high, but as the week nears its close the 
morning temperature is likely to fall to a lower level 
(ioi° to 102° F.— 38.3 to 38.9 C). The pulse may 
become very rapid and weak and perhaps dicrotic. 
The tongue becomes more dry and cracked, and the 
patient may be unable to protrude it. Bed-sores may 
appear and retention of urine and incontinence of 
feces may occur. The nervous symptoms become more 
marked, the twitchings are more noticeable and the 
patient may pick at the bed-clothes and grasp at imagi- 
nary objects. Intestinal hemorrhage may be evidenced 
by blood-tinged stools or blood in considerable quan- 
tity may flow from the rectum, leaving the patient in 
collapse with a sudden fall in temperature, impercept- 
ible pulse and other evidences of extreme prostration. 
Congestion of the lungs or pneumonia is likely to com- 
plicate the disease in this week. Distention of the 
abdomen by gas is not infrequent. The patient may 
die or go on to 



ENTERIC FEVER. 99 

The Fourth Week, — Now the morning temperature 
falls still lower and the evening rise gradually be- 
comes less until the former reaches normal and the 
evening 101 to 102 F. (38.3 to 38.9 C.)- As the 
fever diminishes the other symptoms gradually ameli- 
orate, the tongue becomes moist, the pulse stronger and 
the nervous manifestations disappear. A returning 
appetite may evidence the patient's improvement. 

The Fifth Week, — The patient may go on to com- 
plete recovery, the fever may last two or three weeks 
longer in severe cases, or after a normal temperature 
lasting several days a relapse may take place. 

Convalescence is slow. The patient is extremely 
weak, although he feels well and is extremely hungry. 
He is able to sit up only a few minutes at a time and 
walking is well-nigh impossible. Relapses may be 
brought on by slight errors in diet or by over-exertion. 
The patient should not be allowed up for at least a 
week and he should not be permitted to walk before 
the tenth day. There may be dysmenorrhea and there 
usually is some loss of hair. Full strength may not be 
recovered for a number of months. 

Menstruation usually take place early in the disease 
as in health, but in the later weeks and in convalescence 
may be absent. Pregnant women, though they rarely 
contract typhoid fever, frequently abort during its 
course. L cf c 



ioo FEVER NURSING. 

Complications. — -Thrombosis of the veins is a fairly 
frequent complication, and is caused by the stoppage of 
the flow of blood through a vessel by a clot. It occurs 
most often in the veins of the thigh and is indicated by 
swelling, edema and tenderness of the affected part. 

Hemorrhage from the Intestine occurs in about four 
per cent, of all cases ; there may be only slight streaks 
of blood in the stools or a free hemorrhage which may 
or may not result in death. It is usually caused by the 
ulcers in the intestine eating through the coats of the 
blood-vessels and is most frequent in the third week. 
It may appear without warning and if large, results in 
immediate collapse with its attendant symptoms. 

Perforation of the Bowel is less frequent and is the 
most serious complication of the disease. It occurs 
usually in the third week and is the result of the ulcers 
eating their way entirely through the wall of the intes- 
tine. It is usually evidenced by sudden acute pain in 
the abdomen, rapid fall of temperature and marked 
collapse. Peritonitis results and is indicated by vomit- 
ing, abdominal distention, tenderness and rigidity. 

Peritonitis without perforation may occur by exten- 
sion of the inflammation within the intestine to the peri- 
toneum surrounding it. 

Abscesses in various parts of the body may appear. 
These give the usual symptoms of abscesses from ordi- 
nary causes. 



ENTERIC FEVER. 101 

Typhoid Spine is a rare complication and is the result 
of inflammation of and around the bodies of the verte- 
brae. 

Bronchitis of mild or severe type occurs frequently 
at the onset and is evidenced by cough and more or less 
muco-purulent expectoration. 

Pneumonia may complicate the disease early or in 
the later stages. In the latter case it may be over- 
looked, for frequently the symptoms are not well 
marked. 

Neuritis (inflammation of the nerves) is fairly com- 
mon and may occur during the course of the disease or 
in convalescence. Its onset is marked by great pain 
and tenderness along the course of the affected nerves. 
There may be a slight degree of paralysis, usually in- 
volving the extensor muscles of the limbs and evi- 
denced by wrist- and foot-drops. 

Bed-sores may develop in severe cases and in those 
not well cared for. They are an unnecessary and dan- 
gerous complication. 

Albuminuria is common and when merely due to the 
infection is of little significance. It may, however, go 
on to a true nephritis. 

Various other complications are described but are of 
more or less rarity. 

Typhoid Fever in Children. — The disease is fairly 
common in children but is rare in infants. Its course 



io2 FEVER NURSING. 

is mild and the symptoms, except the mental dulness 
and apathy, are usually not well marked. 

Typhoid Fever in Old Persons. — After the age of 
forty the disease is rare but of severe course, and al- 
though the temperature may not reach a high level, 
complications, especially pneumonia and heart weak- 
ness, are frequent. 

The Widal Reaction is an aid in the diagnosis of 
the disease and is based upon the fact that the blood of 
a typhoid patient when added to a culture of the bacillus 
causes the organisms to aggregate into " clumps " and 
to lose their motility. In the city of New York the 
health department employs bacteriologists who make 
this test upon specimens of blood sent in by physicians. 
A specimen is prepared by drawing from the patient's 
ear and collecting upon either end of a glass slide two 
good-sized drops of blood. These are allowed to dry 
and the specimen is then ready for examination. 

Prevention. — Since the disease is caused only by 
the entrance into the system of bacilli from other 
patients the greatest attention on the part of the nurse 
should be given to the proper disinfection and disposal 
of all excreta. It is entirely insufficient to empty these 
into the various receptacles provided for their disposal, 
but it is absolutely necessary that they should be prop- 
erly disinfected according to methods such as those 
described in the section upon disinfectants. Likewise 
the bed-clothing, bath water, the patient's garments 



ENTERIC FEVER. 103 

and all objects and utensils with which he or the nurse, 
after handling him, comes into contact, must be sub- 
jected to thorough disinfection before being used again. 
After his recovery the sick-room with all its furniture 
should be treated in accordance with the directions laid 
down in the section upon room disinfection. 

The typhoid fever patient is unlikely to be a source 
of danger to those about him, provided these precau- 
tions are taken and the nurse is scrupulously clean in 
dress and person, always changing the former, steriliz- 
ing her hands and washing her face before going to 
meals and upon leaving the sick-room for exercise, etc. 
She should also be very careful never to use her mouth 
as a receptacle for pins, pencils and the like, since 
carelessness in this regard may cost her her life. 

Anti-typhoid Inoculation. — Recently attempts have 
been made with some success to prepare a serum which, 
when injected into healthy persons, may render them 
immune to typhoid fever, and experiments upon the 
English soldiers during the Anglo-Boer war in South 
Africa lead us to believe that individuals so inoculated 
are much less prone to contract the disease, and when 
they do suffer from it are much more likely to recover 
than those uninoculated. Unfortunately immunity so 
conferred lasts only for a period of weeks. It may be 
safely affirmed that the measure is one which, in prop- 
erly selected cases, is not dangerous, and should not be 



io4 FEVER NURSING. 

neglected when there is probability of exposure to the 
disease. 

Treatment. — The specific treatment of typhoid 
fever by means of an antitoxin has as yet given no very 
favorable results. 

The value of the antiseptic treatment of typhoid 
fever has never been questioned. The only difficulty 
is how best to secure its efficiency. This may be done 
most efficaciously by the administration early in the 
disease of certain intestinal antiseptics such as beta- 
naphtol bismuth or eudoxin, and after the first week 
of chlorin water in drachm doses every three or four 
hours. In such doses chlorin water can be safely ad- 
ministered until complete disinfection of the alimentary 
tract is obtained. Under its use the tongue becomes 
cleaner, the appetite and digestion better, the fever 
lower, and the stools devoid of odor save that due to 
chlorin. The general strength, intellectual processes 
and the nervous conditions improve, the disease is 
shortened and the patient usually proceeds to a rapid 
and complete recovery. 

During the course of the disease a daily movement 
of the bowels should be secured by means of rectal 
enemata. 

At the present time the treatment of typhoid fever 
by the Brand, or more properly the Currie-Jurgensen 
bath, is enjoying considerable vogue. Brand's original 
method has been modified so that the consensus of 



ENTERIC FEVER. 105 

opinion is now in favor of tub bathing at a temperature 
of from 8o° to 90 F. (26.7 to 32.2 C), although 
certain authorities believe that tubbing at 98 F. 
(36.7 C.) produces quite as good results and is much 
less disturbing to the patient. The duration of the 
baths is usually ten minutes. The patient should be 
lifted both into and out of the bath; he should be 
immersed to the neck and the head should be covered 
with an ice cap or cold cloth. Throughout the pro- 
cedure the subject should be gently but thoroughly 
rubbed by the hands of at least two attendants. Stimu- 
lants should follow the bath and in weak patients should 
precede it. At the conclusion of the measure the 
patient should be dried in the recumbent posture, and 
if chilly, warmly covered. Fresh water should be used 
for each bath. 

Sponges, sprinkle baths, cold wet packs, evaporation 
baths and bags of cold water may be used when tubbing 
is contraindicated, but are much less efficacious. Per- 
haps the best substitute for the tub bath is the bed bath. 
This is given upon a bed around the edges of which 
have been placed rolled blankets. Over these is placed 
a rubber sheet into which two or three pailsful of water 
are poured. The patient is placed in the trough thus 
made and is treated in the same manner as when the 
tub is used. 

The frequency of the baths is governed by the height 



106 FEVER NURSING. 

of temperature, the severity of the nervous symptoms, 
the strength of the pulse and the general condition. 
The slightest indication of hemorrhage or peritonitis; 
extreme heart weakness; arterio-sclerosis ; pneumonia; 
pleuritic effusion ; phlebitis and old age are contraindi- 
cations to tub bathing. The menstrual period and 
pregnancy do not absolutely contraindicate. Obese 
persons should be bathed with care. There are pa- 
tients who, for no apparent reason, do not bear tubbing 
well, and in these cases it is wise to omit the process. 

When heart weakness occurs in the course of the dis- 
ease it may be controlled by alcohol and other stimu- 
lants. The headache, restlessness, sleeplessness and 
delirium may be controlled by hot or cold applications 
and sedative drugs. Bismuth and opium may be given 
if the stools become too frequent. The genito-urinary 
tract may be rendered less septic and the urine less in- 
fectious by the administration of urotropin in doses of 
five grains three times a day. The drug should be well 
diluted and thoroughly dissolved, and must be given 
with care. It is well to use it in the later weeks of 
the disease and during convalescence if not throughout 
the whole course of the infection. 

This and all the drugs mentioned above must never 
be given by the nurse save when directed by the attend- 
ing physician. 

The disease in children may be managed in practi- 
cally the same manner as in adults. Tub baths are 



ENTERIC FEVER. 107 

however less well borne and fortunately the disease 
runs a milder course in the younger patients. 

The Treatment of Complications. — At the least 
sign of intestinal hemorrhage the strictest quiet must 
be enjoined; the patient must not be moved even to 
have his soiled linen changed, and food must be tem- 
porarily stopped. When feeding is begun again only 
such foods as are digested in the stomach and upper 
part of the intestine, such as beef -juice or peptonized 
milk, should be given and these in very small quantities 
at a time. If the patient is being bathed the baths must 
be omitted. Applications of cold in the form of com- 
presses or the ice-coil should be made to the abdomen. 
If there are signs of collapse the foot of the bed must 
be raised and upon the physician's order hypodermatic 
stimulation administered (whiskey) and either hot nor- 
mal saline injected directly into a vein or under the 
skin of the thighs or buttocks may be necessary. 
Drugs calculated to stop the bleeding may be ordered 
by the medical attendant. 

Perforation of the Bowel. — When this takes place 
quiet is absolutely necessary until a surgical operation 
can be performed which should be done as soon as 
possible after the diagnosis has been made. 

Peritonitis calls for the enforcement of complete 
quiet, the application of cold to the abdomen and great 
care in the administration of food. 



io8 FEVER NURSING. 

Tympanites (abdominal distention by gas) may be 
diminished by the insertion of a rectal tube, by the 
application of hot-water bags or turpentine stupes to 
the abdomen, by the administration of a few drops of 
turpentine internally or by high rectal injections of hot 
saline solution upon the physician's order. Often by 
stopping the milk for from 24 to 48 hours we may pre- 
vent the formation of gas. In the interval broths and 
albumen water may be given. 

Thrombosis is treated by the elevation of the affected 
part and by cold applications. The patient must re- 
main quiet lest bits of the clot become dislodged into 
the circulating blood and cause thrombosis elsewhere. 

Bed-sores should be guarded against by the strictest 
attention to cleanliness (see p. 54). 

Constipation may be overcome by mild laxatives or 
by enemata of soapsuds. The latter should not be 
large and must always be given from a fountain 
syringe, with great care and only upon the physician's 
order. 

Recrudescences and Relapses. — The management of 
the latter is identical with that of the disease itself, but 
the former are a more serious matter ; in them only the 
mildest hydrotherapeutic measures should be used and 
heavy stimulation may be necessary. 

The Diet. — While the febrile movement is present 
only fluid diet is allowable. Most patients do well 
upon a diet of milk alone, the quantity necessary for an 



ENTERIC FEVER. 109 

adult being about two quarts per day, six ounces being 
given every two hours. The milk may be cold, warm 
or boiled, as the patient prefers. It may be more ac- 
ceptable if a little Vichy or other carbonated water be 
added or if flavored with a few teaspoonfuls of French 
coffee. When milk cannot be tolerated matzoon, 
kumyss or buttermilk may be substituted. If milk dis- 
agrees the tongue becomes heavily coated and tympa- 
nites, constipation or diarrhea with undigested curds in 
the stools may ensue. Such symptoms may be relieved 
by diluting the milk with equal parts of lime water or 
Vichy, by peptonizing the milk or by replacing it with 
a diet of beef, lamb or chicken broths and albumin 
water. The broths may prove more palatable when 
flavored with various vegetable extracts (onion, celery, 
etc.). The different prepared foods (malted milk, 
plasmon, etc.) and gruels may be tried; an occasional 
cup of cocoa will do no harm. 

If the patient goes to sleep quickly after being 
wakened, feeding should be continued at proper in- 
tervals during the night ; otherwise one or two feedings 
must be omitted. 

The nurse must always record the total quantity of 
food taken each day. 

Fluid diet as a rule should be continued for one week 
after the temperature has fallen to normal, but some 
patients, after all the symptoms have disappeared, con- 
tinue to have an evening rise of temperature of two 



no FEVER NURSING. 

or three degrees (F.) ; to such, if the nutrition is im- 
paired and the need of food is manifest a gradual re- 
turn to solid diet may be allowed. Usually the tem- 
perature promptly subsides and no harm is done. 

The articles of solid food which are allowed first are 
puree soups, broths with rice, milk toast, soft-boiled 
eggs, junket and the like (see section on the diet of 
fevers in general, p. 64 and ff.). 

Relapses and recrudescences necessitate an imme- 
diate return to fluid diet. 

Nursing. — In a private house the bed should, when 
possible, be in a large, light, well-ventilated room from 
which all hangings and superfluous furniture have been 
removed. The temperature should not be above 70 F. 
and it is better to have it as low as 6o° F. In favor- 
able weather the windows should be open. Too bright 
light and too much darkness are to be avoided. The 
bed should not be too heavily covered, the bed linen 
must be frequently changed and kept perfectly smooth. 
In severe cases the air or water bed may be necessary. 
Early in the disease the patient should lie on his back, 
but later the nurse should encourage him to change his 
attitude so as to guard against pulmonary congestion 
and bed-sores. The mouth, teeth and tongue should 
be frequently cleansed. Studious attention should be 
given to the proper cleanliness of the body and all points 
at which bed-sores are likely to develop should receive 
special care. The bowels and bladder should be evacu- 



ENTERIC FEVER. i« 

ated only when the patient is lying on his back; the 
stools must be carefully watched for blood and milk- 
curds and if these occur they must be at once reported 
to the physician. The quantity, color and sediment of 
the urine must be noted. 

When involuntary movements and urination are un- 
avoidable, the soiled bed-clothing must be immediately 
replaced by clean linen, and disinfected. In such cases 
the change is greatly facilitated by having two beds 
and moving the patient when necessary from one to the 
other; at least two attendants are necessary for this 
process since the patient must remain absolutely 
passive. 

The apartment should be kept quiet and free from 
disturbance of any kind for complete mental inactivity 
on the part of the patient is necessary. On this account 
visitors and all distractions should be forbidden. 

It is best to have two nurses, and a member of the 
family may be allowed in the room when additional aid 
is needed. The bed should be of single size and high, 
with a firm, comfortable mattress protected by a rubber 
sheet. The clothing under the patient must be kept 
smooth to prevent bed-sores and in warm weather if he 
wears no night-shirt and is covered only by a sheet he 
will be more comfortable and will be spared the incon- 
venience of being undressed for each bath if these are 
given. Under these circumstances, wrinkling of the 



H2 FEVER NURSING. 

clothing under him will be less likely to occur. The 
possibility of taking cold is very slight. 

The patient's head should be kept low and nourish- 
ment should be administered through a tube or from 
a spouted cup. Temperature, pulse and respiration 
should be taken every three hours, but at night, unless 
the fever is above 103 F. (38.5 C), it is wise to 
allow the patient to sleep without interference. He 
should not be allowed to see the temperature chart lest 
he be subjected to undue worry about his condition. 

If the mind is clear it is well to explain the danger 
of attempting to sit up and of sudden movement, and 
if there is the least sign of mental aberration or de- 
lirium the patient must not be left alone for an instant. 

The nurse should assist the patient to change his 
position at intervals during the later weeks of the dis- 
ease even if he does not complain of discomfort. 

On points other than those mentioned above the 
nursing of enteric fever should be carried on in accord- 
ance with the principles laid down in the sections on 
fever nursing in general. 

Paratyphoid Fever. 
This disease differs in no essential from true typhoid 
fever except in its causation. This is a bacillus inter- 
mediate in form between the true typhoid bacillus and 
the common colon bacillus. The symptoms, course, 
treatment and nursing of the two diseases are practi- 



WEIL'S DISEASE. 113 

cally identical, in fact their differential diagnosis is im- 
possible except by demonstrating the organism in the 
patient's blood or excreta. All that has been said in 
the previous section with regard to typhoid fever, ex- 
cept the paragraphs upon preventive inoculation and 
serum treatment, applies also to the paratyphoid infec- 
tion. In the latter disease the sera for preventive in- 
oculation and treatment must of necessity be products 
of the growth of the paratyphoid bacillus. 

Weil's Disease. 

Synonym.— Acute febrile jaundice. 

Definition. — Weil's disease is an acute infectious 
fever, characterized by severe pains in the muscles, 
jaundice and a remittent temperature, which falls by 
crisis or rapid lysis. 

1 Causation. — It usually occurs in the summer 
months and is most commonly seen in young adult 
males. Its specific cause is probably a microorganism 
which has not yet been identified. 

Course and Symptoms. — The incubation period is 
usually about one week. The onset is sudden with 
a chill followed by fever, headache and severe pains 
in the muscles. About the second day jaundice ap- 
pears, which may later become more pronounced, and 
is accompanied by itching. The temperature ranges 
from about 103 to 104 F. (39.5 to 40 C), but may 
reach 107 F. (41.6 C). There may be vomiting 



H4 FEVER NURSING. 

and diarrhea; rarely there is delirium or coma. The 
liver and spleen are enlarged and tender ; the urine con- 
tains bile pigment, albumin, casts and perhaps blood. 
The stools may be clay-colored. The disease usually 
continues from five to eight days, when the fever falls 
and the symptoms abate. The mild cases usually re- 
cover rapidly, the more severe ones may be protracted ; 
ultimate recovery however is the rule. 

The disease derives particular interest from the fact 
that it is easily confounded with enteric fever. 

Treatment. — The treatment is entirely sympto- 
matic. The headache may be relieved by compresses; 
the muscular pains may be controlled by rubbing with 
some counter-irritating liniment ; the bowels should be 
kept open and during the febrile stage the patient 
should be kept in bed. 

Diet. — The complicating nephritis makes a fluid 
diet absolutely necessary. When the . temperature has 
fallen and the nephritis has subsided, a gradual return 
to ordinary diet is proper. 

The nursing is to be conducted along the general 
lines. 

Typhus Fever. 

Synonyms. — Jail, camp, ship, hospital, putrid or 
spotted fever, black death. 

Definition. — An acute infectious disease charac- 
terized by a typical skin eruption, nervous symptoms 
and a high temperature terminating usually by crisis in 



TYPHUS FEVER. 115 

about two weeks. The disease was very common in 
olden times but is becoming comparatively rare be- 
cause of the increased attention paid to sanitation. 

Causation. — It is most common in young adults 
but no age is exempt. Filthy conditions, unhygienic 
surroundings, poor ventilation, etc., favor the occur- 
rence of the disease. Typhus fever is probably caused 
by a microorganism which has not yet been discovered. 
The contagion is easily acquired and difficult to de- 
stroy; it seems to float in the air and to be given off 
from the surface of the patient's body ; consequently the 
disease is communicable from person to person and 
through clothing, bedding, furniture and the like. The 
contagion cannot be carried through the air from hos- 
pitals to dwellings in the vicinity. Typhus patients 
give off in the breath and from their bodies a peculiar 
odor, and persons who perceive this most acutely seem 
to be most apt to contract the disease. If the sick- 
room is thoroughly ventilated, visitors spending only a 
few moments with the patient are not likely to become 
infected. It is believed that the patient's excreta do 
not spread the disease. Typhus fever is most easily 
contracted by persons in poor condition and unhealthy 
surroundings, but few escape if sufficiently exposed. 
It is unusual for one individual to suffer two attacks. 

Course and Symptoms. — The incubation period 
varies from a few hours to twenty days. These ex- 
tremes are rare, however, the usual period being from 



n6 FEVER NURSING. 

eight to twelve days. The average duration of the dis- 
ease is from twelve to fourteen days. 

The most noticeable symptoms are fever, headache, 
mental symptoms and the eruption. 

The onset is usually sudden with a chill followed by 
fever, severe headache and pains in the back and limbs ; 
there may be nausea and vomiting; the bowels are 
usually constipated. During the first week the face is 
congested and apathetic, and during the second week 
the patient's appearance resembles that of the third 
week of typhoid fever. After the initial chill the tem- 
perature rises rapidly and reaches its greatest height 
(usually 104 to 106 F. — 40 to 41. i° C.) from the 
fourth to the seventh day. At first the fever is prac- 
tically continuous, but as the second week begins there 
are morning remissions. 

The pulse is at first rapid (100) and full, later it is 
likely to become rapid and feeble or it may remain slow 
and feeble or rapid and feeble throughout the disease. 

The respirations are rapid and this rapidity may be 
increased during the second week as a result of pulmo- 
nary complications. 

The rash is constant and appears from the fourth to 
the seventh day and lasts from seven to ten days. 
There is but one crop and it appears on arms, legs and 
body, but is most typical on the front of the forearms 
and shoulders. It is in the form of irregular, slightly 
elevated, rounded, pinkish blotches from the size of a 



TYPHUS FEVER. 



117 



pinhead to that of a split pea. Later in the disease the 
spots become darker in color and the intervening skin 
may be reddened or mottled. From the eighth to the 
tenth day small ecchymoses within the blotches, which 
have now become brownish in color, may appear, and 
small bluish petechiae may manifest themselves. These 



DAY OF -I ( 
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Clinical Chart of Typhus Fever Ending in Recovery. 

last may persist after the disappearance of the original 
rash. After the eruption has disappeared desquama- 
tion usually takes place. Children, in whom the dis- 
ease is rarely fatal, sometimes show no rash whatever, 
and are quite likely to be free from the petechiae. 



n8 FEVER NURSING. 

The urine is diminished, darkened in color, increased 
in acidity and is likely to contain albumin and casts. 

The marked nervous symptoms such as alternating 
delirium and stupor, muscular twitching, picking at the 
bed-clothing, etc., appear in the second week. 

In the favorable types of the disease, at the end of 
the second week the temperature falls rapidly, the 
symptoms subside, the patient is able to sleep and con- 
valescence is established. 

Relapses are rare and bronchitis and broncho-pneu- 
monia are the most frequent complications. 

The prognosis of typhus fever is always grave. 

Prevention. — The spread of the disease should be 
guarded against by isolation of the patient and the 
strictest quarantine. All the excreta, bed-clothing, 
utensils, the sick-room, etc., should be disinfected as in 
typhoid fever. It is very important that the apartment 
should be thoroughly aired for several weeks after hav- 
ing been subjected to the process of disinfection. 

Treatment. — The patient should be confined to 
bed, his diet should consist entirely of fluids, milk, 
broths and the like, and he should be encouraged to 
drink copiously of cold water. After convalescence 
has begun solid diet may be allowed within a few days. 

No drug is known which exerts any specific influence 
upon the disease, but the symptoms are treated as they 
arise. 



YELLOW FEVER. 119 

It is of the utmost importance that there be an abund- 
ance of fresh air in the sick-room. During the last 
epidemic in New York it was found that those patients 
bore the disease best who were treated in tents in the 
open air. 

For the fever, if above 102 F. (38.9 C.) cold baths 
may be given ; the bowels should be kept open by mild 
laxatives; the employment of whiskey or other stimu- 
lants may be necessary to combat the heart weakness. 
For the nervous symptoms various sedatives are indi- 
cated. 

The nurse should endeavor to spend most of the 
time, when not in actual attendance upon the patient, 
near an open window or in fresh air. Otherwise the 
nursing of the disease should be conducted along the 
lines laid down for the nursing of febrile disease in 
general. 

Yellow Fever. 

Definition. — An acute infectious febrile disease 
evidenced by jaundice, vomiting of blood and extreme 
prostration. The disease is endemic in the West 
Indies, Central America and the west coast of Africa. 
From time to time epidemics have appeared in the 
southern United States. 

Causation. — The specific germ of yellow fever has 
not yet been discovered beyond question. It is trans- 
mitted to man through the bite of a certain species of 



i2o FEVER NURSING. 

mosquito which has previously fed upon the blood of 
those ill with the disease. It is not probable that in- 
fection is carried in clothing, ships, etc. Young in- 
fants and the aged are likely to escape. Whites are 
more susceptible to the contagion than negroes. Epi- 
demics cease after a frost, as the low temperature kills 
the mosquitoes. An individual who has suffered one 
attack is very unlikely to be infected a second time. 

Course and Symptoms. — The incubation period 
varies from three to six days. The invasion of the 
disease is extremely acute and marks the commence- 
ment of 

The First Stage, — The onset is marked by chilly 
feelings or a convulsion with rapid rise of temperature 
to io2°-io5° F. (38.9 to 40.5 C). With slight 
variations the fever lasts from three to four days, fall- 
ing by lysis. There are severe headache and general 
pains, sore-throat, vomiting, restlessness and great 
prostration. The face is flushed, the eyes reddened and 
watery and there is dread of bright light. The pulse is 
weak and slow in proportion to the height of the tem- 
perature and may become slower than normal before 
the fever declines. The tongue is red and dry and the 
gums are sore. The patient vomits, first the contents 
of the stomach, then mucus, bile and blood. The 
bowels are usually constipated but the stools are not 
light in color. The urine is scanty, high-colored, and 
usually contains albumin. About the second or third 



YELLOW FEVER. 



121 



day the whites of the eyes become yellowish and later 
jaundice appears over the entire surface of the body. 



OAY OF 

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Clinical Chart of a Yellow Fever Patient showing the pulse typically slow 
in comparison to the height of the temperature. 

The Second or Stage of Calm appears when the fever 
declines ; the symptoms gradually disappear and the 
9 



122 FEVER NURSING. 

patient goes on to recovery or after a period lasting 
from a few hours to a day or two he becomes worse 
and continues to 

The Third Stage, which is marked by extreme pros- 
tration, normal or elevated temperature, soft and very 
slow pulse, and hemorrhages. Bleeding into the stom- 
ach and the vomiting of the partly decomposed blood 
(black vomit) occurs, and tarry stools may be observed. 
Hemorrhages from the nose, gums, uterus, kidneys and 
into the skin are not infrequent. The jaundice persists 
and there may be suppression of the urine followed by 
convulsions and death due to uremia. 

If the patient recovers the symptoms slowly amelio- 
rate and prolonged convalescence takes place. 

Complications and relapses are rare. 

The disease may vary from the regular type and be 
very mild, lasting but two or three days, and showing 
none of the usual symptoms; or it may be malignant 
with little or no rise in temperature and early stupor 
or coma followed in three or four days by death. 

Prevention. — Quarantine, in the light of present 
knowledge of the method of transmission of yellow 
fever, seems unnecessary, but as a precaution it is best 
to isolate the patient. 

Prevention consists chiefly in protection from and 
destruction of the mosquitoes. How effectually this 
prevents the disease is evidenced by its rarity in Ha- 
vana since proper steps have been taken in this direc- 



YELLOW FEVER. 123 

tion. Mosquitoes in dwellings may be destroyed by 
sulphur fumigation and prevented from entering by 
screens. 

Patients suffering from the disease should be sur- 
rounded by netting. Curative and preventive inocula- 
tion by various serums seems to be of little use. Even 
though it seems improbable that yellow fever can be 
transmitted by means of clothing and the like it is wise 
to disinfect the patient's apartment and all articles with 
which he has come in contact according to the methods 
employed after smallpox and the other infectious dis- 
eases. 

Treatment. — The patient should not be moved 
after the onset of the disease and strictest quiet must 
be enjoined. If the patient cannot urinate while lying 
in bed he must be catheterized. All body and bed 
linen must be changed with the utmost care to disturb 
the patient to the least possible degree. 

The symptoms should be treated as they arise. Dur- 
ing the active stage all food and medicine must be 
given per rectum or hypodermatically, never by the 
mouth. 

Hypodermatic injections of morphine upon the 
physician's prescription and cracked ice may be given 
for the vomiting and a mustard plaster or hot poultice 
may be applied to the abdomen. No purgatives should 
be given. Suppression of the urine may sometimes be 
relieved by hot packs over the region of the bladder, 



124 FEVER NURSING. 

high rectal enemata of normal salt solution and alkaline 
diuretics. The hemorrhages are difficult of control. 

Diet. — During the acute stage all food should be 
given per rectum; during convalescence the greatest 
caution is to be observed in feeding, for solids given 
too soon are likely to provoke hemorrhage. No solids 
should be given for at least ten days after the symptoms 
have subsided. At first the patient may have pepton- 
ized milk or kumyss, a drachm every half hour, then 
beef juice may be allowed, also whites of eggs and in- 
fant foods, broths and gruels. Gradually may be 
added the various semi-solids, junket, cereals, etc., and 
so on till the patient is strong enough to tolerate solid 
diet. 

The nursing of yellow fever requires no other in- 
structions than those given in the chapter on fever nurs- 
ing in general. 

Influenza. 

Synonyms, — Epidemic catarrhal fever; la grippe. 

Definition. — An epidemic febrile disease charac- 
terized by catarrhal inflammations of the various mu- 
cous membranes, prostration and a tendency to involve- 
ment of the digestive and nervous systems. In- 
fluenza occurs from time to time in wide-spread epi- 
demics. 

Causation. — The disease is more common and 
severe in adults than in children, and though it pre- 



INFLUENZA. 125 

vails at all seasons, it is more fatal in the colder months. 
Bad sanitary surroundings do not seem to affect its 
incidence and persons who have suffered from the dis- 
ease seem more prone to contract it than others. The 
specific cause is a bacillus which is found in the exuda- 
tions from the inflamed mucous membranes — especially 
in the nasal discharge and sputum — and in the blood. 

Course and Symptoms. — The incubation period is 
from a few hours to several days; the onset is sudden 
with a chill followed by a rise in temperature — 101 to 
104 F. (38.4 to 40 C.) — severe headache and mus- 
cular pains ; there may be nausea and vomiting together 
with the other symptoms usual in beginning febrile dis- 
ease. The fever lasts from two to six days and may be 
of remittent or intermittent type ; the pulse is rapid and 
in old persons may be feeble. During the course of 
the disease various skin eruptions may appear. As the 
temperature approaches normal, sweating is likely to 
occur and the symptoms gradually subside. 

The disease manifests itself in one of three main 
types, which are very likely to merge into one another. 

The Catarrhal Type is characterized by symptoms 
referable to the mucous membranes of the respiratory 
tract and conjunctivae. There are sneezing, nasal dis- 
charge, a feeling of fulness in the head, sore-throat, 
hoarseness, and the eyes congested. The cough is 
at first dry, but soon muco-purulent sputum appears; 
rarely it may be blood-stained. Bronchitis and pneu- 



126 FEVER NURSING. 

monia of severe form are not infrequent complica- 
tions. Recovery is slow and the cough may persist for 
weeks. 

The Nervous Type begins with severe headache, 
ringing in the ears, general muscular pains and extreme 
depression and prostration; rarely there may be con- 
vulsions. In some cases there are symptoms resem- 
bling those of meningitis, such as sensitiveness to light 
and sound, pain in the back of the head, and stiffness 
of the muscles of the neck. Delirium sometimes oc- 
curs. The nervous symptoms gradually subside in the 
course of a few days, but during convalescence there is 
marked tendency to mental depression and neuralgia in 
various parts of the body. True neuritis is a frequent 
sequel. 

The G astro-intestinal Type is evidenced by vomiting, 
cramps in the abdomen, distention and diarrhea; the 
symptoms may be so severe as to suggest peritonitis or 
appendicitis. Jaundice may be present. 

Complications. — The most common of these are 
bronchitis, pneumonia, which is usually of severe char- 
acter, and neuritis. Various other complications such 
as pleurisy, inflammations of the heart and pericardium, 
conjunctivitis and otitis are less frequent. 

Influenza in old persons or those previously weak- 
ened by disease is always serious and often fatal. 

Prevention. — During epidemics it is wise to avoid 
undue exposure to cold and wet and to keep the body 



INFLUENZA. 127 

in as hygienic a condition as possible. If there is any 
tendency to nasal or throat inflammation the daily use 
of an antiseptic spray is advisable. 

Quarantine of patients suffering from the disease is 
hardly necessary, but all needless association with suf- 
ferers is to be avoided. 

Treatment. — At the onset the patient should go to 
bed and an attempt may be made to shorten the disease 
by means of free opening of the bowels and the induc- 
tion of sweating by the administration of a hot pack 
and hot drinks. 

If the disease continues despite these measures, treat- 
ment calculated to relieve the symptoms should be 
undertaken. The pains may be controlled by hot or 
cold applications and the administration of phenacetin 
when ordered by the physician ; the nose and throat in- 
flammations should be treated with antiseptic sprays 
or applications. In cases with marked prostration 
heavy stimulation may be necessary. 

The Diet during the febrile stage should be of 
fluids and it is very important that the patient's nutri- 
tion be maintained. As convalescence begins semi- 
solids may be allowed, with solids to follow as soon as 
they are tolerated; the patient should be encouraged 
to eat as much as he can assimilate. Various tonics 
such as malts, fat emulsions and cod-liver oil are useful 
at this juncture. 



128 FEVER NURSING. 

In nursing there need be no departure from the usual 
principles. 

Malta Fever. 

Synonyms. — Mediterranean fever ; Neapolitan fever ; 
rock fever; undulant fever. 

Definition. — An infectious fever characterized by 
an irregular temperature, sweats, diffuse pains and a 
tendency to relapse. 

Causation. — The disease is endemic in Malta and 
epidemics occur from time to time in the countries 
bordering on the Mediterranean ; it is occasionally seen 
in tropical America. It attacks young adults most 
frequently and prevails chiefly in summer and in un- 
hygienic environments. Its specific cause is the ba- 
cillus melitensis, which is believed to enter the body 
upon the inspired air. 

Course and Symptoms. — The incubation period 
lasts from a few days to two weeks. The invasion 
is slow, with headache, restlessness, prostration, consti- 
pation and sometimes bloody stools. The temperature 
is slightly elevated and the spleen is enlarged. The 
temperature, after remaining high for from one to four 
weeks, falls to normal and remains there for a period 
of from one to three days when a relapse, often of a 
more severe character than the first attack, takes place. 
The symptoms are increased in severity, the tempera- 
ture, though intermittent, is high, there may be delirium 



MOUNTAIN FEVER. 129 

and diarrhea. These symptoms may last five or six 
weeks. A second temporary convalescence is followed 
by a second relapse in which severe joint pains are 
usually present. After the second relapse the patient 
may go on to recovery or a third relapse may ensue 
after an afebrile period lasting several months. The 
mortality is not great, death when it takes place being 
due to the continued high temperature or to exhaustion. 

Complications. — Broncho-pneumonia and pleurisy 
sometimes occur; arthritis and orchitis are more rare. 

Prevention consists in avoidance of the localities 
in which the disease prevails. So far as we are at 
present aware little else can be done in this regard. 

Treatment is stimulative and supportive. High 
temperature may be controlled by bathing, the joint 
pains by applications of heat or cold. 

Diet. — The diet applicable to typhoid fever is suit- 
able in this disease. 

The nursing is to be carried out along the usual 
lines. 

Mountain Fever. 

Synonyms. — Spotted fever; tick fever. 

Definition. — An acute infectious disease charac- 
terized by a typical skin eruption, recurring chills and 
high fever. 

Causation. — The disease occurs in the Rocky 
Mountain regions of Idaho and Montana. It attacks 



130 FEVER NURSING. 

all ages and both sexes, and is most frequently observed 
during the months from March to July. Its specific 
cause is a microorganism resembling that of malaria, 
which is conveyed to the patient through the bite of a 
certain form of tick. This organism exists in moder- 
ate numbers in the blood of patients suffering from the 
disease. 

Course and Symptoms.— The period of incubation 
is from three to ten days. The period of invasion is 
marked by malaise ; the onset by a distinct chill, which 
recurs at intervals during the disease, decreasing in 
severity, headache, pains in the bones, and prostration. 
The initial chill is followed by a rapid rise in tem- 
perature which by the second day reaches 103 or 104 
F. (39-5° to 40 C). It gradually increases to a 
maximum of 105 to 107 F. (40.5 to 41.6 C.) from 
the fifth to the seventh day. The temperature is high- 
est at night, being slightly lower in the morning. 
About the middle of the second week the fever begins 
to fall by lysis, reaching normal on the fourteenth day. 
Occasionally the temperature falls to normal or below 
a few hours before death. The bowels are usually con- 
stipated ; there is often a bronchial cough. The tongue 
and facial expression resemble those of typhoid fever, 
and in severe types of the infection, nervous symptoms 
resembling those of that disease are to be expected. 

The pulse at the onset is full and strong, becoming 
rapid and weak as the severity of the disease increases. 



MOUNTAIN FEVER. 13 1 

The appetite during the first week of the disease is 
often good. At the beginning of the second week 
nausea and vomiting appear and in fatal cases may con- 
tinue. The spleen is enlarged. The respiration is 
rapid and regular, but shallow. It may reach 60 but 
is usually about 40. 

As a rule the prognosis is good with proper care. 

The eruption appears on the second to the fifth day, 
first upon the wrists, ankles or back. Thence it 
spreads, covering the whole body. It may progress so 
rapidly as to cover all the skin in twelve hours, but 
usually the height of the eruption is reached in one or 
two days. The rash is frequently present upon the 
scalp, palms and soles. It at first consists of rose- 
colored, circular spots from the size of a pinhead to that 
of a small pea. They are not elevated and in the be- 
ginning disappear on pressure; they may be tender. 
They quickly become permanent and dark-blue or pur- 
plish in color and increase in size until the skin assumes 
a marbled appearance. Sometimes the eruption con- 
sists of small brownish spots which give a speckled ap- 
pearance to the skin. 

Desquamation begins during the third week and as 
the fever falls the spots fade but may not wholly dis- 
appear for weeks or months. There is usually jaun- 
dice. The skin may become gangrenous over the 
elbows, fingers, toes or scrotum. 



i3 2 FEVER NURSING. 

Prevention. — The districts in which the disease 
occurs should be avoided during those months in which 
mountain fever is prevalent. Measures should be 
taken to avoid tick-bites, but when these take place the 
insect should be removed at once by the application of 
turpentine, ammonia or kerosene, and the wound cau- 
terized with pure carbolic acid. 

Treatment. — The use of quinin in large doses 
hypodermatically has given favorable results in the 
few cases in which it has been employed. Otherwise 
the treatment of the disease is purely symptomatic. 

The Diet and nursing suitable to typhoid fever 
may be employed with advantage in mountain fever. 

The nursing should be conducted in accordance with 
the general principles. 

Acute Miliary Tuberculosis. 

Synonyms. — Acute tuberculosis ; acute general tuber- 
culosis. 

Definition. — An acute febrile disease characterized 
by the formation of miliary tubercles in various organs 
of the body and accompanied by constitutional symp- 
toms closely resembling those of typhoid fever. 

Causation. — Acute tuberculosis may follow local- 
ized tuberculosis of lungs, bones, joints or glands, or 
occur in individuals in whom tuberculosis in any form 
has not been previously recognized, although it is prob- 



ACUTE MILIARY TUBERCULOSIS. i33 

able that these patients have had undemonstrated tuber- 
culosis of some organ or tissue. The specific cause of 
the disease is the tubercle bacillus, which in some man- 
ner has entered the circulating blood in considerable 
number and has been deposited in the various organs 
by means of this medium. 

Course and Symptoms. — The disease resembles 
typhoid fever to so marked an extent that differentia- 
tion may be very difficult. The onset is slow with in- 
creasing weakness, headache, nausea, constipation and 
fever. The temperature is irregular, being low in the 
morning and high at night — I02°-I05° F. (38.9 - 
40.5 ° C.) — and is accompanied by sweating; the pulse 
is rapid (140-150) and the respirations are accelerated 
(36-70) ; there may be blueness of the lips and ex- 
tremities. Cough is usually present; the sputum is 
scanty, mucoid and may or not contain the bacilli. 
Fever sores upon the lips are not rare. Otherwise the 
symptoms so resemble those of typhoid fever as to need 
no further description in a work of this character. The 
disease is invariably fatal. 

Varieties. — There are several varieties of the in- 
fection : 

(a) The Typhoid Type, in which many of the ner- 
vous symptoms of typhoid fever are present. 

(fe) The Meningeal Type, in which there are hyper- 
sensitiveness of all the senses, convulsions, stiffness and 



134 FEVER NURSING. 

pain in the back of the neck and finally coma with 
paralyses. 

(c) The Pulmonary Type, which is characterized by 
distressing cough, extreme shortness of breath and 
blueness of lips and extremities. 

(d) The Abdominal Type, in which there are dis- 
tention and tenderness of the abdomen. 

Treatment is entirely symptomatic. The high 
fever may be controlled by bathing, the heart weakness 
combated by stimulants, and the cough and nervous 
symptoms relieved by sedatives. Otherwise the treat- 
ment of the symptoms of typhoid fever is applicable. 

The Diet and nursing should also be based upon 
the principles already described for typhoid fever. 

Chronic Pulmonary Tuberculosis. 

Synonyms. — Chronic phthisis ; consumption. 

Definition. — A chronic disease characterized by 
progressive emaciation, obstinate cough with the ex- 
pectoration of muco-purulent matter and sometimes of 
blood, fever and night sweats. 

Causation. — The disease is predisposed to by an 
hereditary tendency, by unhygienic methods of life and 
unhealthful surroundings. Its specific cause is the 
tubercle bacillus which reaches, either through the 
blood stream or upon the inspired air, the interior of 
the lungs and there causes a tuberculous inflammation. 

Course and Symptoms. — Sometimes the disease 
gives few recognized symptoms until the inflammation 



CHRONIC PULMONARY TUBERCULOSIS. 13S 

in the lungs has made considerable progress, but usu- 
ally the patient becomes aware that his condition is not 
as it should be by the appearance of persistent cough, 
of pulmonary hemorrhage, of progressive loss of flesh 
and strength, of chilly and feverish feelings or of night 
sweats. 

The temperature of the disease is not constant; it 
may remain normal for considerable periods but usually 
it shows a remittent curve, being about ioo° F. 
(37.8 C.) in the morning and rising in the afternoon 
to 102 or 103 F. (38.9°-39.5° C.) ; with the fever 
there are chills and sweats, clammy perspiration at 
night being a feature of the disease. 

The pulse is moderately increased in rate and as the 
prostration increases becomes progressively more 
feeble; both pulse and respiration are quickened by 
slight exertion. Usually the respiration, even when 
quiet, is faster than normal, but the patient seldom 
complains of shortness of breath. 

x\s the disease goes on the patient gradually loses 
flesh, his cheeks become sunken and flushed (the 
" hectic flush ") ; the color of the skin is otherwise pale 
or it may be bluish over the extremities ; the spaces 
above and below the clavicles are sunken, the ribs are 
prominent, and the abdomen hollowed. 

The appetite is poor, the tongue is coated, and there 
may be nausea and vomiting caused by the swallowed 
sputum. Late in the disease there is likely to be diar- 



I3 6 FEVER NURSING. 

rhea due to a complicating tuberculous inflammation 
of the intestinal lining. 

The cough may be dry or there may be mucopuru- 
lent sputum in greater or less quantities. A consider- 
able quantity of purulent sputum may be raised upon 
the occasion of the rupture of an abscess in the tissues 
of the lung. The sputum may be streaked with blood 
and at times hemorrhages may take place, not rarely 
so profuse as to end in death. The sputum contains 
the tubercle bacilli in greater or less number. 

There may be pain in the chest due to a complicating 
pleurisy. 

Tuberculous laryngitis accompanied by hoarseness, 
a laryngeal cough, pain and difficulty in swallowing is 
a common complication. 

In women menstruation is irregular or stops entirely. 

A feature of the disease is the fact that the patient is 
cheerful and no matter how ill he may be is very hope- 
ful of recovery. 

Prevention. — Persons with an inherited tubercu- 
lous tendency should be careful to avoid exposure to 
cold and wet and endeavor to lead as healthful lives as 
possible. 

Since the sputum of this disease contains the tubercle 
bacilli the greatest care should be exercised in its dis- 
posal. 

It should always be expectorated when indoors into 
paper cups which may afterward be burned or into 



CHRONIC PULMONARY TUBERCULOSIS. 137 

vessels containing a disinfectant solution (i to 10 car- 
bolic acid solution or I to 2,000 mercury bichlorid) and 
when the patient is out of doors he should be provided 
with an appropriate pocket flask. If cloths should be 
used they must be burned as soon as possible. Great 
care should be taken by the patient to prevent the 
hands, face and clothing from becoming contaminated 
by the matter coughed up. If they do become soiled 
they should be washed at once with soap and hot water. 
When coughing or sneezing, particles of moisture are 
expelled which may contain the bacilli, consequently a 
cloth, which must subsequently be burned, should be 
held before the mouth during these acts. Male pa- 
tients should always keep the face cleanly shaven. 

All the patient's personal and bed linen should be 
handled as little as possible when soiled and should 
be placed in water until ready for washing. His apart- 
ment should be subjected to periodical disinfection ac- 
cording to one of the usual methods. 

When the patient is too weak to properly dispose of 
his sputum all utensils and clothing which become con- 
taminated must be cared for as described in the chapter 
upon disinfection, and fumigation of rooms previously 
occupied by tuberculous patients should undergo the 
process usual after the infectious diseases. 

The stools of patients with tuberculous disease of the 
intestine may also contain the bacillus and these with 
10 



i3 8 FEVER NURSING. 

all articles contaminated by them should be disposed 
of as set forth in Chapter IV. 

Attendants should avoid standing in front of the 
patient when he coughs, for minute particles of sputum 
containing the bacilli may be by this .act projected into 
the atmosphere and infect those with whom they come 
into contact. 

Treatment. — The object in the treatment of this 
disease is to improve the general bodily nutrition. 
The patient's apartment should be large, airy, sunny 
and without carpet or draperies. He should spend as 
much time as possible in the outdoor air, in bad weather 
being properly sheltered and wrapped during his air- 
ing. At night the room should be freely ventilated, 
no matter how cold the weather, but avoidance of 
draughts is necessary. 

Exercise in moderation, but not when it tires the 
patient nor when fever is present, may be indulged in. 
When the disease is advancing rapidly, when there is 
marked fever, and when complications arise, he should 
be kept in bed. 

When in the open air the patient should periodically 
draw several long breaths through the nose so as to 
thoroughly aerate the lungs. A sponge bath with 
water at a moderate temperature should be given daily. 
The underclothing should be of wool and of moderate 
weight. Pajamas of flannel are to be preferred to the 
ordinary night gown. 



CHRONIC PULMONARY TUBERCULOSIS. 139 

The drugs most used in the treatment of this disease 
are cod-liver oil and creosote or some of its derivatives. 
The latter is frequently given by inhalations from a 
mask made of perforated metal which may be worn 
as long as desired. The appliance contains a sponge 
which is moistened with a mixture of equal parts of 
creosote, chloroform and alcohol. Tonics are often 
useful. 

The night sweats may be controlled by the adminis- 
tration of various drugs, or by waking the patient about 
four o'clock in the morning and giving him a glass of 
warm milk containing a little whiskey. This proced- 
ure possesses the additional benefit of supplying a little 
extra food. 

If the sputum is foul the inhalation of the vapor of a 
few drachms of turpentine added to a kettle of steam- 
ing water is beneficial. 

Pulmonary hemorrhage should be treated by insist- 
ing upon absolute quiet in bed and the application of an 
ice bag to the chest. 

The internal administration of calcium chlorid, supra- 
renal extract and subcutaneous injections of gelatin 
solution have been advocated. No medication, how- 
ever, should be administered unless ordered by the 
physician. 

For patients able to travel a change of climate is 
frequently beneficial. A climate which agrees with the 
patient under treatment should be chosen. Some do 



140 FEVER NURSING. 

best upon the seashore, others at high altitudes. There 
is no way of determining in advance whether or no a 
certain climate will prove beneficial. 

The Diet in chronic phthisis is a most important 
consideration. The secret of feeding tuberculous pa- 
tients is to give them light, nutritious, easily digested 
food and to feed them early and often. The patient 
should have at least three hours in which to digest the 
heavier meals so that the stomach may be emptied 
before the next feeding. At seven o'clock in the morn- 
ing the patient should receive a glass of warm milk con- 
taining a tablespoonful of strong French coffee. If 
the previous night has been an exhausting one, whiskey 
may be substituted for the coffee. Before being added 
to the milk, the spirit should be diluted with an ounce 
of water, lest it cause coagulation and render the mix- 
ture indigestible. Breakfast should be taken about 
nine o'clock and may consist of eggs, cooked in any 
way except by frying. If the patient insists upon hav- 
ing them fried, olive oil or butter must be used instead 
of lard. Bread, toast or cold rolls with butter, milk 
and coffee may complete the meal. 

About eleven o'clock the patient receives a second 
breakfast consisting of a cup of cocoa from which the 
fat has been extracted, or coffee, with bread and a little 
soup or beef extract. An egg-nog is permissible and 
kumyss or matzoon is often acceptable. 

The dinner should be served about one o'clock and 



CHRONIC PULMONARY TUBERCULOSIS. M* 

may consist of any kind of fresh meat, but it must not 
be fried. Potatoes, fresh vegetables, fruits and pud- 
dings may also be allowed. Coffee, tea or possibly a 
bottle of light beer may be added. 

About four in the afternoon the patient should take 
a little meat extract with toast, and about five o'clock a 
little more should be given. About seven o'clock in the 
evening comes supper consisting chiefly of farinaceous 
food with the addition of various jellies, beef extracts 
and gruels. If the patient is awake at eleven a cup of 
milk, hot soup or gruel may induce sleep. 

Patients, whose temperature rises in the afternoon 
should usually take no alcohol after the one o'clock 
meal. In other cases the only alcohol permissible in 
the afternoon is light beer or possibly stout at bed time. 

Especially in patients with complicating tuberculous 
laryngitis and in others when indicated, forced feeding 
by gavage (Debove) accomplishes good results. 

The food is prepared as follows : Lean meat from 
which all the gristle and tendon and much of the fat 
have been removed should be used. The meat should 
be chopped fine and dried in an oven at 150 F. 
(65. 6° C.) until it has become absolutely dry. Now 
the temperature of the oven should be raised to about 
170 F. (76.7 C). When the meat has been thor- 
oughly dried, which takes a number of hours, it should 
be ground in a mortar and sifted. Six pounds of raw 
beef treated in this way furnish about one pound of the 
beef powder. 



142 FEVER NURSING. 

In administering the food a stomach tube — not a 
stomach pump — is used. This tube should be of soft 
rubber, of three eighths to one half an inch outside 
diameter and with an opening both at the side and at 
the extremity of its tip; a glass funnel should be at- 
tached to the other extremity. At about sixteen inches 
from the tip of the tube should be a mark so that we 
may know when the stomach has been reached. 

Before passing the tube it should be lubricated by 
pouring upon it a few drops of glycerin which should 
be allowed to run down its outside to the tip. Then 
grasping the appliance between thumb and forefinger 
at about six inches from its tip, the nurse should stand 
directly in front of the patient and as the mouth is 
opened pass the tube along the dorsum of the tongue. 
As the tip reaches the back of the throat the nurse 
should rotate it and tell the patient to swallow. As he 
does this the tube should be quickly and gently passed 
down the esophagus until it reaches the cardiac end of 
the stomach; as the tube passes this point a distinct 
sensation is perceived by the nurse. Care should be 
taken that the appliance is not passed into the trachea 
instead of into the esophagus. If this accident happens 
air will be breathed through the tube and the patient 
will experience difficulty in respiration. In the event of 
such an occurrence there is nothing to do but to with- 
draw the tube and begin over again. In patients with 
very sensitive throats it may be necessary to employ 



CHRONIC PULMONARY TUBERCULOSIS. 143 

a spray of cocain solution (four per cent.) or to 
administer bromides before the procedure. 

The tube being in the stomach, the organ should be 
washed, in order to cleanse its wall of mucus, by pour- 
ing in a pint of artificial Vichy water. After washing, 
the Vichy should be withdrawn by lowering the funnel 
when the wash water will flow out by siphonage. 

The stomach having been washed the nurse should 
proceed with the feeding of the patient by pouring into 
the organ through the tube three-quarters of a pound 
of the beef powder to which has been added three times 
as much milk (two and one fourth pints). This is to 
be left in the stomach. At first such a meal should be 
given twice a day and the amount gradually increased 
until the patient takes from one to one and one half 
pounds of the powder and four or five pints of milk 
per day. If there is trouble in digesting this the milk 
should be omitted and a little diluted hydrochloric acid 
added to the meat powder. In no case should the 
hydrochloric acid be used if milk forms a part of the 
feeding. 

In the late stages of chronic phthisis when the 
patient's digestion will not permit the administration of 
solid food and weakness forbids feeding by gavage we 
must have recourse to a diet consisting of milk, soups, 
gruels and the like. 

The nursing in other regards is to be conducted as 
usual in febrile diseases. 



CHAPTER VI. 

INFECTIONS OF CONTINUED TYPE WITH LOCAL 
MANIFESTATIONS. 

Pneumonia: Diphtheria: False Diphtheria: Acute Articular 
Rheumatism: Erysipelas: Septicemia: Puerperal Fever: 
Pyemia: Mumps: Bubonic Plague. 

Pneumonia. 

Synonyms.— Pneumonitis ; fibrinous pneumonia ; 
croupous pneumonia; lung fever. 

Definition. — Pneumonia is an acute infectious 
fever characterized by inflammation of the lungs. 

Causation. — The disease is common in all coun- 
tries and occurs at all ages; it is particularly fatal in 
infancy, old age and alcoholic individuals. It is most 
frequently seen in the cold and damp months. Ex- 
posure to cold and wet, alcoholic excess, previous 
catarrhal affections of the lungs and disease of the 
heart predispose to the infection. During epidemics of 
influenza pneumonia is likely to be prevalent and at- 
tended with an increased mortality. Several attacks in 
the same person are not infrequent. 

Various bacteria are found in the sputa of pneumonia 
patients, the most common of which are the micro- 
coccus lanceolatus or diplococcus of Frankel, the ba- 

144 



PNEUMONIA. 145 

cillus pneumonia? of Friedlander and ordinary staphy- 
lococci and streptococci. It is probable that pneu- 
monia is in a sense infectious, for although physicians 
and nurses seldom contract the disease from association 
with patients, it is not uncommon for several cases to 
occur in the same house or to develop in a hospital 
ward following the admission of a patient suffering 
from the infection. The sputum probably is the means 
through which the contagium is carried. 

Course and Symptoms. — The incubation period is 
unknown, but in all probability is from a few hours to 
three days. The onset as a rule is sudden with a 
marked chill followed by a rapid rise in temperature, 
sharp pain in the side, cough and shortness of breath; 
the pulse is rapid and tense ; there is extreme prostra- 
tion. A frequent early symptom is herpes of the lips 
or nostrils. The cough is at first dry but after two or 
three days a blood-stained expectoration appears — the 
so-called " rusty sputum " — which is so viscid that it 
adheres firmly to the sides of the containing vessel; 
in certain cases the sputum is not so viscid and dark 
brown — " prune juice sputum." After the tempera- 
ture has fallen the sputum becomes lumpy and yellow- 
ish or greenish in color. The pain in the chest is 
severe and knife-like in character, is usually felt in the 
axilla over the affected lung, and is increased upon 
breathing or coughing. It tends to become less marked 
as the disease progresses. The patient is likely to be 



146 FEVER NURSING. 

more comfortable when lying upon the affected side, 
because in this position less motion of the involved 
lung is possible. 

The pulse is rapid and full at the onset of the disease 
but not so rapid as to retain the normal pulse-respira- 
tion ratio, later it becomes weaker, irregular and per- 
haps dicrotic. There is always danger of heart failure. 

The shortness of breath is a prominent symptom and 
may be accompanied, especially in children, by move- 
ment of the nostrils. The respirations are shallow— 
from 30 to 50 per minute — and in children even more 
rapid than these figures. In some cases expiration is 
accompanied by a grunting sound. Blueness of the 
lips and extremities may be present with extreme res- 
piratory difficulty. Nervous symptoms such as stupor, 
and delirium are common. In alcoholic cases delirium 
tremens is a frequent complication. 

The temperature reaches its highest point within a 
few hours after the onset and remains elevated, with 
slight morning remissions, until the crisis — which 
usually takes place upon the seventh day — when it falls 
within a few hours to normal. With this occurrence 
the other symptoms abate. In children and old persons 
defervescence is more likely to take place by lysis as is 
also the rule in cases protracted beyond the tenth day. 

Complications. — A dry pleurisy accompanies all 
cases of pneumonia in which the inflammation ex- 
tends to the surface of the lung. Pleurisy with effus- 



PNEUMONIA. 



147 



ion is not infrequent and may, especially in children, go 
on to empyema in which latter case chills, sweating 



11 12 1 13 



6 I 7 1 S I 9 10 [ 



EE 



14 15 16 17 IS 



m 



107 

I 104 

< lo-r 



9 



I* 



1: 



I 



a 



is 



~41° 



r«8 3 



-40 3 



K 



KO 

140 

ISO 

a 112. 

3 wo 

90 



in! 




ill 



Clinical Chart of Acute Lobar Pneumonia showing pulse and respiration. 
Defervescence upon the seventh day of the disease. 

and a remittent temperature should lead us to suspect 
the presence of pus. 



148 FEVER NURSING. 

Bronchitis may make the disease more severe and 
increase its exhausting effects. 

Pericarditis may occur and is due to an extension of 
the inflammation to the membranes surrounding the 
heart. 

Endocarditis is not rare. 

Jaundice may occur, especially in alcoholic cases. 
With this complication the sputum may be tinged 
yellow or green. 

Meningitis may exist as a complication and is evi- 
denced by headache, stiffness of the neck, unequal 
pupils, stupor or delirium. 

Varieties of the Disease. — Wandering Pneumonia 
is the term applied to that variety of the disease in 
which different areas in the lungs become successively 
inflamed. 

Typhoid Pneumonia has no connection with typhoid 
fever but is the term applied to that type of the disease 
in which the patient is rapidly overcome by the toxemia. 
The temperature may remain low or it may reach a 
high level. The nervous symptoms are marked and 
the tendency to heart failure is great. 

Alcoholic Pneumonia occurs in individuals who use 
liquor to excess. It is typified by a severe course, and 
a tendency to delirium tremens. It is very fatal. 

Pneumonia in Infants. — The onset may be marked 
by a convulsion. The temperature is irregular and 
usually falls by lysis. The mental symptoms are 



PNEUMONIA. 149 

severe and, though there may be cough, there is usually 
no expectoration, since if it be present at all it is usually 
swallowed. 

Pneumonia in Old Persons is characterized by a pro- 
tracted course and moderate temperature which as a 
rule falls by lysis ; the prostration is extreme, the pulse 
is weak, the respiration shallow. This variety is 
usually fatal. 

Prevention. — All sputum should be disinfected 
and after the disease is over the sick-room should be 
fumigated after the usual manner. 

Treatment. — The patient should be kept in bed 
and absolutely quiet in a well-ventilated room at a 
temperature of about jo° F. He should not be allowed 
to rise or to lift his head, under any circumstances. 
The bowels should be kept open throughout the course 
of the disease. 

A pneumonia jacket of cotton batting and oil-silk 
fitted to the chest may make the patient more com- 
fortable. Poultices or ice-bags applied to the inflamed 
lung do not influence the disease, but may relieve pain. 
The former may be made of antiphlogistine or flax- 
seed. 

The antiphlogistine may be used by applying several 
turns of a three- or four-inch roller bandage to the 
chest, spreading the substance in a thin layer upon that 
portion of the bandage which covers the affected por- 
tion of lung and covering it with further turns of the 
bandage. 



15° FEVER NURSING. 

A flax-seed poultice is made by mixing flax-seed 
meal and boiling water in proper proportions in a bowl. 
When thoroughly beaten together the mixture should 
be spread to the thickness of one half an inch upon a 
piece of linen slightly larger than the surface to which 
the application is to be made; a border of linen must 
be left all around the mixture of flax-seed meal and 
water when it is spread; this is to be folded over the 
edge of the poultice when completed. The poultice 
should be applied as hot as the patient can bear it, but 
the nurse must take care not to burn the skin. In re- 
newing poultices it must be remembered that a surface 
to which continuous hot applications have been made 
will not bear a poultice so hot as that first applied. If 
the poultice cannot be applied immediately after it has 
been made it should be kept warm between two plates 
placed over a vessel of boiling water, not in the oven. 

The fever may be controlled by sponging with 
alcohol and water and a luke-warm tub bath is an ex- 
cellent measure in the case of children. 

Few drugs have any influence upon the course of the 
disease. The use of creosote carbonate however is 
frequently followed by beneficent results. It should be 
given, however, only upon the physician's order. We 
endeavor to keep the pulse between 90 and 100 and 
of good strength. With this the respiration will be 
easier and the tendency to cyanosis diminished. The 
drugs best suited to this purpose are alcohol, and other 



DIPHTHERIA. 15 1 

cardiac stimulants. When the dyspnea is marked and 
the blueness of lips and extremities extreme the ad- 
ministration of oxygen is valuable. It may be given 
continuously or at intervals and in cases which it does 
not benefit it certainly does no harm. 

Treatment other than that described above should 
be calculated to relieve the various symptoms as they 
arise. 

After convalescence has begun the patient should be 
kept in bed for a week and given general tonic treat- 
ment. 

The Diet during the febrile stage should be entirely 
of fluids, milk, broths, gruels, etc., and should be 
administered either through a tube or by means of a 
cup with a spout adapted to the purpose. 

The nurse should above all things be quiet and care- 
fully observant of the slightest changes in the patient's 
condition. In this disease, as in few others, thoroughly 
efficient nursing is absolutely necessary. 

Diphtheria. 

Synonym. — Putrid sore-throat. 

Definition. — Diphtheria is an acute infectious febrile 
disease, occurring sporadically and as an epidemic and 
marked by inflammation with the formation of a false 
membrane in the upper air passages. 

Causation. — It occurs chiefly in children, is rare 
after sixteen years of age and is most common in the 



152 FEVER NURSING. 

colder months. The disease is predisposed to by the 
presence of adenoids and enlarged tonsils. It is of most 
frequent occurrence in unsanitary surroundings, due 
to the fact that these cause general ill-health and lessen 
the resisting power of the body. The specific cause of 
the infection is the Klebs-Loeffler bacillus which grows 
in the false membrane. The bacilli enter upon the in- 
spired air, upon substances conveyed to the mouth or 
by direct contact with an abraded surface ; they are not 
borne upon sewer-gas or emanations from unclean 
drains, etc. The disease is very contagious for the dis- 
tance of a few feet, but its poison is not very diffusible, 
consequently it is quite possible to confine it to a single 
room. The contagium may be carried long distances 
in clothing, etc., and may be transmitted by pet ani- 
mals — cats in particular. Certain persons seem to be 
insusceptible to the infection, for the bacilli have been 
found in the throats of healthy individuals. Pieces of 
membrane coughed up by patients may infect physi- 
cians or nurses or be carried by them to a third person. 
In most cases the ordinary pus germs are found to co- 
exist with the Klebs-Loeffler bacilli. One attack seems 
to render the individual more susceptible to further 
infection. 

Course and Symptoms. — The incubation period is 
usually from two to three days, rarely as long as a 
week; the onset is marked by chills or convulsions 
followed by a rise in temperature to ioo° or 102 F. 



DIPHTHERIA. 153 

(37.8 to 38.9 C.) ; rarely fever may be absent 
throughout the whole course of the disease. The throat 
is sore, swallowing is painful and hoarseness due to 
laryngitis may be present; there are headache, bodily 
pains, nausea, vomiting and prostration; the tongue is 
coated and the breath foul. The severity of the symp- 
toms is usually in proportion to the extent of the local 
inflammation. The pulse is rapid and, throughout the 
disease and during convalescence, there is great dan- 
ger of heart failure of very sudden or gradual onset. 
Shortness of breath is common as a result of obstruc- 
tion of the air-passages. The urine is scanty, high- 
colored and often contains albumin and casts. 

The Malignant Variety. — Cases of this type ap- 
pear during every epidemic, usually in individuals 
whose condition is poor. Such cases are marked by 
prostration so severe that death may take place before 
the membrane appears; in other cases the membrane 
forms very rapidly, the febrile movement is absent, 
there are extreme prostration and heart-weakness, the 
patient may become delirious or comatose and death 
may supervene within a few days. 

The membrane may appear at any of the following 
situations : 

The Pharynx and Tonsils. — The tonsils and pharynx 

are red and swollen. Upon them are one or two small, 

grayish, membrane-like patches which rapidly increase 

in size, the uvula becomes inflamed and sometimes 

11 



154 FEVER NURSING. 

edematous; the glands in the neck become enlarged 
but not tender. The membrane spreads over the back 
of the throat and is grayish or yellowish in color ; after 
about seven days it begins to disappear and within a 
few days is entirely gone. With its disappearance the 
symptoms clear and convalescence begins. 

The Larynx. — When this situation is involved the 
constitutional symptoms are similar to those described, 
with the addition of marked hoarseness, noisy breath- 
ing and a croupy cough. In some cases the voice may 
be lost and as the membrane spreads, the difficulty in 
breathing becomes extreme; the lips become blue and 
the patient's expression very anxious. Bits of mem- 
brane may be coughed out, but usually this gives no 
permanent relief, for new membrane forms. In severe 
cases of this type all the symptoms become accentuated, 
lung complications may occur and death is not unusual. 

The Nose. — In nasal diphtheria there is a thin and 
sometimes very irritating discharge from the nostrils, 
which soon becomes brownish in color and may contain 
blood; the patient snuffles, sneezes and, if the nose is 
entirely occluded, breathes through the mouth. The 
inflammation may extend to the ears and eyes; the 
glands beneath the jaw are swollen. This type varies 
in severity but is as a rule to be dreaded. 

The membrane may involve any two or all of the 
above situations. 

Complications. — Heart Failure is not rare and may 
cause the sudden death of the patient. 



DIPHTHERIA. 155 

Nephritis of mild or severe character is not un- 
common. 

Pneumonia due to the inhalation of bits of mem- 
brane may occur. 

Paralyses are frequent sequels of diphtheria and may 
appear even late in convalescence. They most usually 
affect the motor nerves supplying the muscles of the 
palate, the eye, the vocal cords, or the limbs. Such 
paralyses are seldom permanent. 

The diagnosis of the disease in poorly marked cases 
may be impossible without bacteriological examination, 
consequently it is advisable that the nurse should be 
familiar with the technique of taking cultures from „the 
throat. A culture outfit, consisting of a tube of solidi- 
fied blood serum and a swab encased in a sterile tube, 
is furnished for this purpose by the health boards of 
certain cities. The patient should be placed in a good 
light and, if a child, firmly held. The swab should be 
rubbed against the suspicious area in the nose or throat 
by revolving it between finger and thumb, then, being 
careful that it come into contact with nothing else, it 
should be gently rubbed over the surface of the serum 
in the culture tube ; care should be taken not to break 
the surface of the serum. The swab should then be 
returned to its tube and both tubes stoppered with their 
cotton plugs. The culture then is placed in an incu- 
bator for some hours and finally examined microscop- 
ically. Throat cultures should not be taken directly 



i5 6 FEVER NURSING. 

after antiseptic applications have been made to the 
inflamed surface. 

Prevention. — Since we know the cause of diph- 
theria and its mode of transmission, we should be 
able to do much to prevent its spread. The following 
is a condensation of the rules concerning the disease 
laid down by the New York Health Department. 

If possible one person should take entire charge of 
the patient and no one else except the physician should 
be allowed in the sick-room. The nurse should hold 
no communication with the rest of the family, who 
should not receive or make visits during the illness. 
Discharges from nose and mouth must be received on 
cloths which should be immediately immersed in car- 
bolic acid solution (six ounces of pure carbolic acid 
added to one gallon of hot water and diluted with an 
equal quantity of water). All handkerchiefs, towels, 
bed linen, clothing, etc., that have come in contact 
with the patient, after use must be at once immersed 
without removal from the room in the above solution. 
These should be soaked for two or three hours and 
then boiled in water for one hour. 

The greatest care should be taken in making appli- 
cations to the throat and nose lest the discharges be 
coughed into the face or upon the clothing of the 
attendant. 

The hands of the attendant should always be disin- 
fected by washing in the carbolic solution and in 



DIPHTHERIA. 157 

soapsuds after making applications and before eating. 

Surfaces of any kind soiled by discharges should 
be immediately flooded with carbolic solution. 

All utensils used by the patient must be kept for his 
use alone and not removed from the room, but must 
be washed in the carbolic solution and in hot soap- 
suds. After use the soapsuds should be thrown in the 
water-closet and the vessel which contained it washed 
in the carbolic solution. 

The sick-room should be thoroughly aired two or 
three times a day and swept frequently after scatter- 
ing wet sawdust or tea leaves on the floor to prevent 
the dust from rising. After sweeping, the room should 
be dusted with damp cloths. The sweepings should 
be burned and the cloths soaked in the carbolic solu- 
tion. 

When the disease is recognized shortly after the 
beginning of the illness all hangings and unnecessary 
furniture should be removed from the sick-room. 

After recovery, the patient's body and hair should 
be washed with hot soapsuds, he should be dressed in 
clean clothes, which have not been in the room during 
the illness, and taken from the apartment. 

The quarantine should last as long as the diph- 
theria bacilli are found upon the mucous membranes; 
they may persist for six or eight weeks. 

The nurse and physician should wear, while in the 
sick-room, a gown which covers the clothing com- 



i5 8 FEVER NURSING. 

pletely. This should be kept just outside the apart- 
ment and sterilized directly after use. If the patient, 
while the throat is being examined, should cough in 
the examiner's face, the latter should wash the face 
and hair in soap and water followed by I to 1,000 
mercury bichlorid solution. The hands must always 
be sterilized upon leaving the sick-room. The nurse 
should spray or gargle her throat several times a day 
with a mild antiseptic, such as DobeU's solution. 

It is strongly advisable that the nurse and members 
of the family, if they have been exposed, should re- 
ceive an immunizing dose (ioo to 500 units) of anti- 
toxin and at the first sign of sore-throat a full dose 
must be given. The effect of an immunizing dose 
lasts about four weeks and at the close of this period 
a second dose should be given if there is continued 
exposure. 

After removal of the patient the room and its con- 
tents should be disinfected and aired in the manner 
described in Chapter IV. 

Treatment. — The patient should be kept in bed 
during the acuity of the disease; even in hospitals a 
separate room for each patient is to be preferred. 
Cases complicated by pneumonia should be isolated un- 
der all circumstances. The apartment should be kept 
cool and freely ventilated. 

The treatment of diphtheria by antitoxin is attended 
with such good results that it is rapidly displacing all 



DIPHTHERIA. 159 

forms of drug treatment. The antitoxin is a yellowish 
transparent fluid and should be administered subcu- 
taneously by means of an ordinary hypodermatic syr- 
inge which has been properly sterilized. The skin of 
the site selected for the injection, usually the thigh, 
the abdomen or the side of the chest, should be 
bathed with soap and water, washed off with 1 to 
5,000 mercury bichlorid solution and the needle punc- 
ture should be covered with a bit of sterile gauze held 
in place by adhesive plaster. The quantity admin- 
istered depends upon the age of the patient and the 
severity of the infection. The initial dose of antitoxin 
should usually be from 1,000 to 2,000 units — a unit 
being the quantity of antitoxin required to neutralize 
the amount of diphtheria poison necessary to kill one 
hundred small guinea-pigs. 

After the injection there is likely to be a slight local 
reaction — pain, tenderness, redness or edema. Var- 
ious skin eruptions may follow the administration of 
antitoxin and these are sometimes accompanied by 
constitutional symptoms. Most commonly the rash 
appears upon the buttocks, abdomen or chest ; there may 
be itching and occasionally there is desquamation. 

The drugs which seem to influence the disease most 
are mercury bichlorid and the tincture of iron chlorid ; 
they, especially the former, must be carefully given. 
The bowels should be kept open by suppositories or 



160 FEVER NURSING. 

enemata; for the heart weakness whiskey and other 
cardiac stimulants may be necessary. 

Local Treatment is an important adjunct to anti- 
toxin, and should be employed even if the patient 
objects. Older children and adults may use sprays 
and gargles, but for young children irrigation is neces- 
sary. In employing this measure the child should be 
tightly wrapped in a sheet to prevent struggling and 
the irrigation tube passed into the mouth — in which 
case the teeth should be kept separated by means of a 
cork — or the nose, allowing the fluid to return through 
the nose or the mouth as the case may be. The child 
should be laid upon a table, with its head low and the 
mouth directed toward the table edge so that the fluid 
may run out and flow over a rubber sheet adjusted for 
the purpose, into a pail upon the floor. The irrigation 
should be of some mild antiseptic solution given luke- 
warm through a soft catheter attached to a fountain 
syringe. If the nose is entirely occluded a passage for 
the catheter must be made along the floor of the nostril 
by means of a probe with a swab of cotton upon its 
end. 

Irrigation does not reach the membranes in the 
larynx and when the disease attacks this situation a 
tent should be made over the child by means of a 
blanket and the tube of a croup kettle inserted through 
an aperture. The inhalation of hot steam exerts a very 
beneficial action upon the inflammation; a little tur- 



DIPHTHERIA. 161 

pentine or creosote added to the water in the kettle 
may increase the good effect. A marked laryngeal 
obstruction may be dislodged by a mild emetic, but 
this should never be employed in weak patients; un- 
der such circumstances the inhalation of calomel vapor 
may be substituted. This process is accomplished by 
closing the tent as tightly as possible and directing into 
it the vapor of ten to thirty grains of calomel burned 
upon a tin plate over a spirit lamp. 

If there is danger of suffocation from laryngeal ob- 
struction either intubation or tracheotomy must be per- 
formed. The former consists in inserting a specially 
constructed tube into the larynx by means of an instru- 
ment adapted to the purpose. Attached to the tube is 
a cord to prevent its being lost in the esophagus or 
trachea. The intubation tube may be worn continu- 
ously for several days or extracted at intervals to be 
cleansed; in some cases it may be necessary to re- 
move it at feeding time; other patients learn to eat 
with it in place. While wearing the tube the patient 
should be kept in an atmosphere of steam and must 
be continuously watched lest the tube become plugged. 

Tracheotomy may be necessary if the obstruction 
extends to the trachea. The operation consists in 
making an opening into the trachea with a scalpel and 
inserting a specially constructed tube. 

The treatment of the complications is that usually 



1 6 2 FEVER NURSING. 

employed in those conditions when they occur ordi- 
narily. 

The Diet should be chiefly of milk and given in 
sufficient quantity — three quarts a day being none too 
much for an adult. There is much more danger of 
under- than of over-feeding. Intubated cases may 
swallow semisolids more easily than liquids and in 
such cases these may be allowed. In cases where swal- 
lowing causes coughing and in intubated cases feeding 
by gavage through the mouth or nose may be necessary. 
Frequently, especially in intubated patients, feeding is 
best accomplished while the patient lies upon his back 
with his head well down. 

With regard to points other than those mentioned 
above the nursing should be conducted according to 
the ordinary rules. 

False Diphtheria. 

Synonyms. — Pseudo-diphtheria ; membranous croup. 

This is a disease which resembles in appearance and 
symptoms true diphtheria but differs from it in causa- 
tion. It may complicate the infectious diseases or oc- 
cur by itself; the membrane does not show the pres- 
ence of the Klebs-Loeffler bacillus but contains the 
ordinary pus germs (streptococci and staphylococci). 
Bacteriological examination is always necessary to dif- 
ferentiate the two diseases. False diphtheria is usu- 
ally milder, shorter and less likely to be followed by 
complications. 



ACUTE ARTICULAR RHEUMATISM. 163 

The treatment, diet and nursing are the same as 
those applicable to true diphtheria, except that the ad- 
ministration of antitoxin is useless. Also, less strict 
quarantine and disinfection are required, although the 
possibility of transmitting the disease from one patient 
to another is not out of the question. 

Acute Articular Rheumatism. 

Synonyms. — Inflammatory rheumatism ; rheumatic 
fever. 

Definition. — An acute febrile disease, probably in- 
fectious, and characterized by inflammation of the 
joints. 

Causation. — A tendency to the disease may be 
inherited. It occurs chiefly in young adults and is 
more common in males than in females. It is predis- 
posed to by exposure to cold and wet, by unhygienic 
environment and mode of life. The specific germ of 
rheumatism has not yet been isolated but it is probable 
that the disease is of infectious origin. 

Course and Symptoms. — The onset of the disease 
is usually sudden. The temperature rises rapidly and 
one or more of the joints becomes swollen, painful, red- 
dened, hot and tender. The tongue is coated and the 
pharynx or tonsils may be inflamed. The joints in- 
volved most frequently are the knees, the wrists, the 
ankles and those of the fingers. It is unusual for the 
inflammation to be confined to a single joint, and fre- 



1 64 FEVER NURSING. 

quently the process travels from one joint to another, 
one improving as another becomes affected. Sweating 
is a prominent feature of the disease. The reaction of 
the perspiration as well as that of the saliva is acid. 
The temperature ranges from ioo° to 104 F. (37.8 
to 40 C.) . The symptoms, unless the disease is treated, 
continue from one to three weeks — then gradually 
ameliorate. Relapses are frequent. When the inflam- 
mation travels from one joint to another the tempera- 
ture rises and the symptoms recur as fresh involvement 
takes place. 

Complications. — Hyperpyrexia is a grave com- 
plication and usually results in death. The tempera- 
ture may rise as high as no° or 112 F. (43.3 or 
44.4 C.y. Various eruptions are occasionally seen, 
and especially in children nodules (erythema nodosum) 
may appear over the tendons upon the back of fingers, 
hands or wrists. Tonsillitis frequently occurs with 
rheumatism and certain authorities believe that it re- 
sults from the same cause. Inflammations of the heart 
and pericardium are very common, especially in young 
patients. 

Chorea is also very frequently seen. 

Prevention. — Persons predisposed to the disease 
should avoid exposing themselves to cold and wet and 
during the cold months should wear woollen under- 
clothes. They should take moderate exercise and en- 



ACUTE ARTICULAR RHEUMATISM. 



165 



deavor to keep the function of digestion in proper 
condition. 

Treatment. — While the inflammation remains 
acute the patient should be kept in bed and warmly 
covered. When it becomes necessary to change his 
position he should be lifted, consequently a muscular 




Clinical Chart of Acute Articular Rheumatism showing renewal of the 
febrile movement consequent upon fresh joint involvement. 

nurse is an essential. The bowels should be kept open 
by saline laxatives. The drug which exercises the 
most beneficial influence over the disease is the sodium 
salicylate given in large doses and in connection with 
the alkalies. Such medication should be given only 
upon a physician's prescription. 



1 66 FEVER NURSING. 

The fever may be controlled by sponge baths; for 
the hyperpyrexia cold packs or tubs are required. 
Local applications of equal parts of guaiacol and glyc- 
erin, of oil of wintergreen, or of glycerin and the 
fluid extract of belladonna will do much to re- 
lieve the pain in the joints. Further comfort may 
be obtained by wrapping the joints in cotton, by 
the application of padded splints, sand bags and small 
pillows adjusted about the inflamed limbs. The joints 
should always be placed in mid-flexion. Very severe 
pain may be mitigated by the application of blisters. 
During convalescence the patient should remain quiet 
and should avoid draughts. Too early return to meat 
diet is to be strongly advised against. 

Pericarditis or endocarditis may be controlled by 
the application of cold over the heart and by sedative 
drugs. 

The Diet during the febrile stage should be entirely 
of fluids. During convalescence a gradual return to a 
solid diet is permissible. The addition of meat to the 
diet should be postponed so long as is possible. 

Alcoholic drinks and sweats also should be avoided. 

The nursing is to be carried on in accordance with 
the usual rules. 

Erysipelas. 

Synonym. — St. Anthony's fire. 

Definition. — An acute, febrile, contagious disease, 
characterized by a chill, intense local redness of the 



ERYSIPELAS. 167 

skin and mucous membrane involved, a remittent fever 
and tendency to recur. 

Causation. — The disease is met most frequently 
in the spring and autumn and amid unhygienic sur- 
roundings. It attacks most commonly individuals ad- 
dicted to alcohol and others who are constitutionally 
weakened. It has been known to become endemic. 
Its specific cause is a germ known as the streptococcus 
erysipelatus, which enters the body through some 
abrasion of the skin or mucous membranes. The 
abrasion may be so small as to escape notice. 

Varieties. — There are various forms of this dis- 
ease but the more important are the following. 

(1) Cutaneous Erysipelas. — The onset is sudden 
with a chill, fever and spots of redness on the skin. 
The fever is high, remittent and terminates on the 
fourth or fifth day, usually by crisis. In young per- 
sons the symptoms are, as a rule, slight, but erysipelas 
in infants, which is likely to follow infection of the 
umbilical cord, is generally fatal; in old persons the 
nervous symptoms may be marked and death usually 
results. 

The red spots tend to coalesce and to become 
slightly elevated. The margins of the infected area 
are sharply defined, red and swollen. As the disease 
progresses the area spreads, the color at the original 
site fading as fresh areas are involved (wandering 
erysipelas). The redness disappears on pressure, to re- 



1 68 FEVER NURSING. 

turn as soon as the pressure is removed. There is 
slight burning pain. Vesicles which may become pus- 
tules appear on the involved part. The eruption may 
vary in shade ; in vigorous persons it is usually bright 
or dark red, dusky when pus is about to form and blue 
when gangrene is about to appear or when there is 
involvement of the heart or lungs. When the inflam- 
mation ceases, the swelling and redness disappear and 
desquamation follows. 

(2) Phlegmonous Erysipelas. — The onset is marked 
by chills, sweats, high temperature— 104 ° to 106 F. 
(40 to 41. 1 ° C.) — delirium and severe prostration. 
The swelling is much more pronounced than in the 
preceding type. It is brawny and may be so intense 
as to produce sloughing or gangrene. Suppuration 
generally takes place, extending into the tissues be- 
neath, into the muscles and even into their sheaths 
and those of the tendons. As the disease progresses, 
sloughs form and fall, leaving ulcers; in some cases 
the muscles, tendons, etc., may be eaten away. This 
type of the disease sometimes follows extravasation of 
urine. 

(3) Cellulitis is that form of erysipelas in which the 
microbe has effected entrance through a wound. The 
swelling, which is not so marked as in the phlegmonous 
variety, appears before the redness, which latter symp- 
tom is not so pronounced as in the cutaneous form. 
The inflammation appears at the edges of the wound 



ERYSIPELAS. 169 

and does not leave the original focus as the disease 
extends. The poison, in mild cases, is disposed of by 
the lymphatic system, but severe cases are marked by 
suppuration in the wound and the adjacent lymph 
glands. 

Complications such as septicemia, pyemia, pneu- 
monia, meningitis and arthritis may arise. 

Treatment. — The first step in all forms of the dis- 
ease is to isolate the patient; he should be kept in 
bed and the wound if evident should be thoroughly 
cleansed with antiseptics; the bowels should be kept 
freely open. In vigorous persons facial erysipelas re- 
quires but little treatment, but in weak and debilitated 
individuals free stimulation is necessary. High tem- 
perature may be controlled by cold bathing. An in- 
jection of a two per cent, solution of carbolic acid 
into the healthy skin just beyond the inflamed area or a 
band of iodin painted upon the skin may arrest the 
advance of the disease ; scarification is sometimes prac- 
ticed. Lead and opium wash, a ten per cent, solution 
of ichthyol in water, or an ichthyol ointment will re- 
lieve the burning pain. In the phlegmonous variety 
the sloughs should be cut and hot or cold fomentations 
applied. Continuous irrigation of the sloughing sur- 
face with an antiseptic solution may be employed. In 
the form characterized by cellulitis disinfection and free 
drainage of the wound by incision are necessary. The 
12 



170 FEVER NURSING. 

constitutional treatment of all forms of the infection 
is supportive and stimulative. 

Injections of antistreptococcus serum have been em- 
ployed in the disease with varying results. 

The Diet during the febrile stage should be of 
fluids and easily digested semisolids. After the tem- 
perature has become normal easily digestible solids 
may be allowed. 

The nurse should pay the utmost attention to the 
condition of her hands and face. She should care- 
fully seal all abrasions of the skin with sterile collo- 
dion and should thoroughly sterilize her hands after 
contact with the patient. Before attending another 
patient she should bathe and wash her hair with mer- 
cury bichlorid solution and all clothing worn while 
in association with the patient should be properly 
disinfected. Aside from these points the general prin- 
ciples of fever nursing are applicable in erysipelas. 

Septicemia. 

Synonym. — Blood poisoning. 

Definition. — A disease due to the existence in the 
blood of any of the pus-forming germs and character- 
ized by recurring chills and irregular febrile movement. 

Causation. — Pus germs may effect entrance to the 
body through any abrasion in the skin or mucous 
membranes. The site of their entrance may be so 
minute as to be impossible of discovery, or it may be a 



SEPTICEMIA. 171 

wound of any size or character. The germs having 
entered the system, either themselves, or the products 
of their growth (toxins) or both these elements give 
rise to the symptoms. 

Course and Symptoms. — Within a few hours after 
infection has taken place the patient suffers from 
chilly feelings, or a distinct chill, followed by a rise 
of temperature. He becomes restless, his skin is hot 
and dry and there may be headache, general pains, 
nausea and vomiting. The pulse is rapid and the 
respiration may be accelerated. These symptoms may 
last but a few days in mild cases and then disappear. 
In severe septicemia the symptoms are greatly intensi- 
fied and those referable to the nervous system are 
very marked. The chill at onset is severe and at 
intervals other chills occur. The temperature rises 
rapidly and may reach 104 to 106 F. (40 to 
41. 1 ° C). In some cases the temperature may fall 
below normal. The prostration is great; the pulse 
is feeble and rapid. As the disease progresses the 
symptoms become those of the typhoid state. The 
tongue becomes brown and dry; the skin is wet with 
cold perspiration. There may be diarrhea. The urine 
is high-colored and is likely to contain albumin and 
casts. The wound which is the source of infection may 
become dry, gangrenous and fetid. 

In progressive septicemia, the symptoms begin less 
acutely and progress less rapidly, otherwise they re- 



i?2 FEVER NURSING. 

semble those just described. The fever may persist for 
a number of weeks; frequent chills and sweats ac- 
company it and various skin eruptions are likely to 
appear. This variety of the disease may be fatal within 
a few weeks, or last for a long time, eventually ending 
in recovery. 

Prevention. — This consists in the careful attention 
to hang nails and other abrasions when they exist. 
When a nurse is employed upon a septic case such 
abrasions should be covered with collodium or, if 
necessary, she should wear rubber gloves. Any wound 
received while in contact with such a patient must be 
immediately cauterized with pure carbolic acid which 
should be quickly washed off with alcohol. In the 
absence of this agent, the wound should be sucked to 
induce free bleeding and dressed antiseptically. 

Treatment consists in keeping all wounds as clean 
and free from septic material as possible and in cer- 
tain cases entire excision of the infected focus. The 
bowels should be kept open by salines ; the fever should 
be combated by cold sponges. Stimulation by means 
of alcohol is frequently necessary. 

The chronic form of the disease, when it is impossible 
to remove the source of the infection, should be treated 
by supportive measures and tonics. 

The Diet should consist of easily digested foods 
in plenteous quantity and should be administered with 
frequency and regularity. 



PUERPERAL FEVER. 173 

Puerperal Fever. 

Synonyms. — Puerperal septicemia; puerperal infec- 
tion; child-bed fever. 

This disease is merely a variety of septicemia in 
which the point of entrance of the infection is the 
uterine mucous membrane. The chief cause is the in- 
complete removal of placental tissue after childbirth. 
The constitutional symptoms are the same as those de- 
scribed under septicemia, and in addition, the discharge 
from the vagina may be profuse and very foul. 

With proper care the disease should be almost en- 
tirely preventable. 

During pregnancy the attending physician should 
treat all inflammations of the vulva, urethra, bladder, 
vagina and uterine cervix so that at the time of de- 
livery there shall be no source from which infection may 
enter the uterus. As the time of labor draws near, the 
patient should be told not to touch her genitals. The 
physician should make as few vaginal examinations as 
possible and these only after thorough cleansing of 
the parts, and sterilization of his hands. The nurse 
should make none at all. In preparing the patient 
for vaginal examination the nurse should first cleanse 
her hands by thorough scrubbing with a brush, soap 
and hot water; she should then cleanse the patient's 
external genitals by means of a cotton wiper wet in I 
to 3,000 mercury bichlorid, and place her in the posi- 



174 FEVER NURSING. 

tion preferred by the physician. If instruments be 
used these must first have been boiled. 

During labor the strictest asepsis with regard to 
hands, instruments and dressings must be maintained. 

If the delivery be instrumental or if manual re- 
moval of the placenta or its membranes becomes neces- 
sary, it is usual to follow these procedures by an intra- 
uterine douche of I to 5,000 mercury bichlorid solu- 
tion given from a fountain syringe which has pre- 
viously been washed with hot 5 per cent, carbolic acid 
solution, and through a glass douche nozzle which has 
been boiled. 

During the puerperium all dressings applied must 
be strictly sterile and manipulated with sterilized instru- 
ments and hands. Should catheterization become nec- 
essary it should be performed in the usual manner 
(seep. 59). 

Treatment. — The general treatment of puerperal 
sepsis is identical with that of septicemia from other 
causes. The special treatment consists in attempting 
to maintain cleanliness in the vagina and uterine cavity. 
This may be done by irrigations of 1 to 10,000 mercury 
bichlorid or one per cent, lysol solution, and by pack- 
ing these cavities loosely with ten per cent, iodoform 
or sterile gauze. 

When the infection is due to retained fragments of 
placenta or membranes these should be removed by 



PYEMIA. 175 

blunt curettage followed by a douche of the composi- 
tion described above. 

Pyemia. 

Definition. — A febrile disease due to infection by 
pus-forming germs which are carried by the blood 
from one part of the body to another., and at their 
points of lodgment set up local infectious processes. 

Causation. — The cause of pyemia has already been 
dealt with in the section devoted to the causation of 
septicemia (p. 170). The pus-forming germs having 
effected entrance to the blood stream, by this means 
are transferred to various parts of the body and cause 
abscesses wherever they may lodge. 

Course and Symptoms. — The symptoms of septi- 
cemia usually precede those of this disease. The onset 
of pyemia is marked by an intense chill, followed by a 
rapid rise of temperature, general pains, vomiting and 
great prostration. The pulse is rapid and weak. 
Chills frequently recur and the temperature curve is 
marked by frequent quick falls and rises. The tem- 
perature often drops to normal or below, and suddenly 
rises to several degrees above the normal level. There 
are frequent sweats. The patient loses flesh rapidly, 
the tongue is dry and the breath may have a sweetish 
smell. There may be diarrhea with foul-smelling 
stools. Sometimes the skin is slightly jaundiced and 
various eruptions may appear. The urine is high- 
colored, scanty, and may contain albumin and casts. 



176 FEVER NURSING. 

Late in the disease delirium and stupor are frequent. 
The patient grows rapidly weaker and there is a 
marked tendency to the formation of bed-sores. As 
the infectious process is set up in the various organs 
certain symptoms occur as follows : 

(a) If in the lung, pain in the chest, shortness of 
breath, and cough with blood-stained expectoration. 

(&) If in the liver or spleen, pain and tenderness 
referred to these organs. As the process goes on to 
abscess formation, local swelling is likely to take place. 

(c) If in the heart, the pulse becomes more rapid, 
the temperature higher and the respiration accelerated. 

(d) In the kidney there may be pain and there is 
usually bloody and albuminous urine. 

Prevention. — The prevention of this disease is 
identical with that applicable to septicemia. 

Treatment. — The treatment resolves itself into 
opening and draining of the abscesses when their situ- 
ation permits. Otherwise pyemia should be managed 
in accordance with the methods already laid down for 
septicemia. 

The nursing of septicemia, puerperal fever and py- 
emia aside from the points mentioned under these dis- 
eases should be conducted along the same lines as those 
proper in general fever nursing. 

Mumps. 
Synonym. — Epidemic parotitis. 



MUMPS. 177 

Definition. — An acute, infectious disease charac- 
terized by inflammation of one or both parotid glands, 
extending occasionally to the submaxillary glands, and 
rarely to the testicles, ovaries and mammary glands, 
and accompanied by mild constitutional symptoms. 

Causation. — The disease is most commonly seen 
in childhood and youth, and usually occurs in the 
winter and spring. It is more common in males than 
in females. By no means all the children exposed 
contract the disease. Mumps spreads by contact in 
most cases but it has been known to be communicated 
through a third person and by clothing. Its specific 
cause is not known, and one attack usually confers 
protection. 

Course and Symptoms. — The incubation period is 
usually about two weeks but may extend to twenty-one 
days. The onset of the disease is marked by chills, fol- 
lowed by a rise in temperature to 101 to 103 F. (38.4 
to 39-5° C.), headache, general pains and prostration. 
In about twenty- four hours one or both parotid glands 
become swollen and tender, the skin over them be- 
comes tense and there may be pain on swallowing and 
sore-throat. An elevation of the lobe of the ear is a 
characteristic sign of parotid swelling. The glands 
may be affected simultaneously or successively; in 
the latter case the disease is prolonged. The inflam- 
mation reaches its height in from three to six days, 
remains stationary for a day or two and then declines. 



178 FEVER NURSING. 

As the swelling goes down the constitutional symp- 
toms ameliorate. Extension of the inflammation to 
the other salivary glands, testicles, ovaries and mam- 
mae protract the course of the infection. 

Complications other than those mentioned above 
and relapses are infrequent. 

Prevention. — The patient and nurse should be 
isolated for at least ten days after the swelling has dis- 
appeared, but the disease is of such mild type that the 
more complicated methods of disinfection are un- 
necessary. 

Treatment. — Rest in bed should be enjoined ; very 
little drug treatment is needed ; the symptoms may be 
controlled as they arise. Hot or cold compresses 
should be applied to the affected glands, the bowels 
should be moved daily and if the testicles are involved 
they should be allowed to rest upon a shelf constructed 
of a strip of adhesive plaster placed across the thighs 
just below the groins. 

The Diet during the height of the disease should 
be entirely of fluids; the nursing may be carried on 
according to usual methods. 

Bubonic Plague. 

Synonyms. — Malignant adenitis; the pest. 

Definition. — An epidemic, contagious, febrile dis- 
ease, characterized by swelling and inflammation of the 
lymph glands and hemorrhages from the mucous mem- 



BUBONIC PLAGUE. 179 

branes. It is common in India and Eastern A 
whence it may be imported into Western countries. 

Causation. — It is most common in the hot months 
and is seldom seen in individuals beyond middle life. 

The specific cause of the disease is the bacillus pesfis. 
This organism enters the body through the respirator}- 
or alimentary tracts or abrasions of the skin and is 
found in the blood of patients and in the pus from the 
suppurating glands. It is given off in the feces, urine 
and sputum, and contaminates clothes, bedding, apart- 
ments and the like. It may be carried by fleas and 
other insects, by rats, mice, dogs, etc. 

Filthy and unhygienic surroundings predispose to 
the occurrence of epidemics. 

Course and Symptoms. — The incubation period 
lasts from two to seven days, during which time the 
patient may feel indefinitely ill. 

The onset proper is fairly sudden with chilly feelings 
followed by high fever — 105 to 106° F. (40.5° to 
41. 1 ° C.) — rapid pulse, and respiration. The head- 
ache and general pains are very distressing, and there 
are all the symptoms of severe infectious disease. 

Vomiting of blood is fairly frequent. 

The mental symptoms are marked and delirium may 
appear early. 

Within a few days the glands of the neck, axillae and 
groins become painful, red, tender and swollen. The 
buboes thus formed may be gradually absorbed 



180 FEVER NURSING. 

or rupture, leaving sinuses discharging pus. Rupture 
is a favorable sign. Carbuncles and hemorrhages into 
the skin are common in some epidemics. 

The fever lasts about a week and then gradually 
falls, the other symptoms ameliorating. The disease, 
however, is attended by large mortality. 

In certain cases the fever is prolonged for a num- 
ber of weeks as a result of septicemic poisoning, and 
in others death from the severe toxemia occurs within 
a few hours. 

The Pneumonic Type is characterized by respiratory 
symptoms and bloody sputum which contains the 
bacillus. 

Prevention.— Quarantine and the strictest isola- 
tion are absolutely necessary, and should be con- 
tinued for a month after recovery. The measures 
necessary for disinfection of excreta, clothing, apart- 
ments, etc., are the same as those described in the 
section relating to smallpox (p. 211). 

Fortunately physicians and nurses who exercise 
proper care seldom contract the disease. 

Preventive inoculations by various serums have re- 
sulted in a very considerable diminution in the death 
rate and the measure is one not to be neglected. 

Treatment. — The usual symptomatic treatment of 
febrile disease is indicated; cold wet applications 
should be made to the buboes until the presence of 



BUBONIC PLAGUE. 181 

pus is evident and then incision and drainage are 
necessary. 

Further research may prove that intravenous injec- 
tions of anti-plague serums are of benefit. 

The nursing is the same as that applicable to other 
actively contagious diseases. 



CHAPTER VII. 

INFECTIONS OF INTERMITTENT TYPE. 

Malarial Fever: Relapsing Fever: Dengue. 

Malarial Fever. 

Synonyms. — Chills and fever ; fever and ague ; palu- 
dism; paludal fever; swamp fever. 

Definition. — An infectious disease characterized 
by paroxysms recurring regularly at various intervals 
and consisting of a chill followed by fever and 
sweating. 

Varieties. — Tertian {single), in which the parox- 
ysms occur every forty-eight hours. 

Quotidian {double tertian), in which the paroxysms 
occur every twenty-four hours. 

Quartan, in which the paroxysms occur every sev- 
enty-two hours. 

Estivo-autumnal, in which the paroxysms occur at 
irregular intervals. 

Pernicious, a remittent malarial fever early in which 
the paroxysms may occur regularly while later in the 
disease the temperature does not fall to normal in the 
interval and may continue high. 

Chronic Malaria {Malarial cachexia) is caused by 
the continuance of any of the above varieties; there 

182 



MALARIAL FEVER. 183 

may be no febrile movement but the disease is charac- 
terized by marked constitutional weakness. 

Causation. — Malaria is less common in the very 
young and in aged persons than in young and middle- 
aged adults ; negroes are less susceptible to the disease 
than whites. Malaria is most common in damp and 
swampy places and the greatest number of cases is ob- 
served in late summer and early autumn. 

The specific cause of the disease is a parasite, the 
Plasmodium malaria, which circulates in the blood, and 
which in reproducing itself causes the paroxysms. 
There are three types of the organism, each causing a 
different form of malaria. These differ somewhat in 
appearance, but the important difference is that their 
life-cycles are of different durations. The tertian form 
reproduces itself every forty-eight hours, the quartan 
form every seventy-two hours, and the estivo-autumnal 
form at irregular intervals. The quotidian, or daily 
type, is due to two sets of the tertian organism re- 
producing themselves upon alternate days so that 
a paroxysm occurs each day. 

It is believed that these forms are merely different 
types of the same organism acting in different ways. 

It has been conclusively demonstrated that the dis- 
ease may be transmitted from one individual to an- 
other by the bites of certain kinds of mosquitoes and 
some observers assert that this is the only means of 
transmission. 



1 84 FEVER NURSING. 

Course and Symptoms. — The incubation period is 
variable, but is usually from ten to twelve days. The 
disease caused by the tertian organism is most common 
in the United States and the estivo-autumnal form is 
the most serious of the three main types. 

A malarial paroxysm consists of a short period 
of invasion during which there may be headache, nau- 
sea and apathy. Then appears the chill which lasts 
from one half to two hours; this usually manifests 
itself late in the morning and almost never at night. 
In children it may be replaced by a convulsion. Dur- 
ing the chill the patient shivers, complains of great 
cold which even hot-water bottles and numerous blan- 
kets may not counteract. There is severe frontal head- 
ache and perhaps nausea and vomiting. The pulse is 
rapid and tense. At the end of one or two hours the 
febrile stage commences; the temperature rises very 
rapidly to 104 or 106 F. (40 to 41. i° C). The 
skin is hot and dry, there is great thirst, there are se- 
vere headache and pains in the back and limbs. The 
pulse is full and rapid. There may even be brief de- 
lirium. The fever lasts from two to twelve hours, 
then falls rapidly to normal or perhaps to a degree or 
two below and the stage of sweating begins. All the 
symptoms subside and there is profuse perspiration. 
The patient may now go to sleep and wake later feeling 
perfectly well. The next paroxysm occurs one, two, or 
three days later and may begin an hour or two earlier 



MALARIAL FEVER. 



i»5 



or later than its predecessor ; in such event it is spoken 
of as anticipated or delayed as the case may be. 

During malaria fever sores on the nostrils or lips 
are common; if the paroxysms are repeated for a 



DAY OF 

DISEASE 


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Clinical Chart of Ordinary or Tertian Malaria showing three 
febrile paroxysms occurring on alternate days. 

considerable time the spleen becomes enlarged and the 
patient becomes anemic. 

In the estivo-autumnal type the paroxysms last from 
sixteen to twenty hours and the fever tends to become 
remittent— from ioo° to 104 F. (37.8 to 40 C.)— 
the beginning chill is milder and gastro-intestinal symp- 
toms — vomiting, abdominal distention, diarrhea — are 
13 



1 86 FEVER NURSING. 

frequently prominent; the headache, restlessness and 
sleeplessness are marked; there may be delirium fol- 
lowed by stupor or coma; the pulse is rapid and fre- 
quently weak. This type of the disease may last from 
ten days to a month or merge into 

Pernicious Malarial Fever. — This variety is rare in 
the United States and occurs in three important forms. 

(a) The Comatose Type, in which there are symp- 
toms of severe cerebral disturbance — delirium or coma. 
The onset may or may not be marked by a chill; the 
fever is high— 106 to 107 F. (41. i° to 41.7 C.)— 
during the paroxysm; there is profuse sweating; the 
pulse is weak and rapid and there is extreme general 
weakness. This variety is usually fatal. 

(b) The Hemorrhagic Type. — There may or may 
not be a febrile paroxysm; the skin is jaundiced; hem- 
orrhages occur from the various mucous membranes or 
into the skin; the urine is diminished and is dark 
either from the presence of blood-pigment or blood 
itself (hemoglobinuric or black-water fever). There 
is restlessness or perhaps delirium. The patient may 
die or the paroxysm may subside, but usually only to 
recur. 

(c) The Algid or Congestive Type (Congestive 
Chill). — This is characterized by severe gastric and in- 
testinal symptoms — the diarrhea in particular may be 
very marked — indefinite chilly sensations with clammy 
skin, blueness and great prostration are frequent. The 



MALARIAL FEVER. 187 

temperature usually is not high and may be sub-normal, 
jaundice is common and the condition is a very serious 
one. 

Malarial Cachexia or Chronic Malaria, is a conse- 
quence of continued attacks of the ordinary forms of 
the disease and is characterized by extreme weakness, 
yellowness of the skin and profound anemia. En- 
largement of the spleen is usual in this as in other 
forms of protracted malaria. Shortness of breath and 
swelling of the feet and ankles are common, and bleed- 
ing from various parts of the body may occur. The 
temperature may continue low or may show irregular 
elevations to 102 to 103 F. (38.9 to 39.5 C). 

Prevention. — The extermination of mosquitoes and 
the draining of swampy lands go far toward lessening 
the frequency of the occurrence of this disease. 

Treatment. — During the chill the patient should 
be kept warm by means of blankets and hot- water 
bottles. The headache may be relieved by hot or cold 
applications. Sponging with cold water may be prac- 
ticed during the febrile stage and the thirst may be 
mitigated by frequent drinks of cold water or lemon- 
ade. During the stage of sweating the nurse may 
make the patient more comfortable by wiping his skin 
with warm flannel. 

Quinin should be given by mouth in the ordinary 
types of the disease but not during the height of the 
fever when it may be vomited ; in the pernicious types 



1 88 FEVER NURSING. 

it should be given hypodermatically and in connection 
with arsenic. 

Malarial cachexia responds best to quinin, in the 
form of Warburg's tincture, and arsenic, with iron and 
various other tonics to build up the system as adjuvants. 
Massage, especially over the splenic region, is useful. 

The diet during the febrile movement should be of 
fluids only, but in the intervals between the paroxysms 
simple solid diet may be allowed. 

With regard to points other than those given above 
for the nursing of malaria, the attendant may conduct 
the case in accordance with the general principles of 
fever nursing. 

Relapsing Fever. 

Synonyms. — Famine fever; recurrent typhus; spiril- 
lum fever; seven day fever. 

Definition. — An acute, epidemic infection charac- 
terized by a febrile movement lasting about six or seven 
days followed by an afebrile interval of about a week, 
after which the febrile paroxysm recurs and may be 
repeated three or four times. 

Causation. — The most favorable conditions for the 
development of the disease are those of famine and 
filth. The specific cause is a spiral-shaped bacterium 
which circulates in the blood, but is not found in the 
stools and other excreta. It is found in the blood only 
during the febrile stage. The infection is transmitted 



RELAPSING FEVER. 189 

by clothing, bed-linen, etc., by personal contact or 
through a third person. Physicians merely visiting 
cases for short periods are less liable to infection than 
nurses. How the organism effects entrance to the 
body is unknown ; possibly it is taken in upon the in- 
spired air or through the skin. The disease occurs in 
both sexes and in all ages, but is rare in the United 
States. One attack does not protect against subse- 
quent infections. 

Course and Symptoms. — The incubation period is 
usually from five to seven days, although it may be 
much shorter. The onset is sudden with a chill fol- 
lowed by fever, severe headache and pains in the back 
and limbs. Sweating is common. The temperature 
rises rapidly and may reach 104 F. (40 C.) upon 
the first day. The pulse is rapid (no to 130). There 
may be severe nausea and vomiting and marked cere- 
bral symptoms. Intestinal derangement is rare; jaun- 
dice is not infrequent. The spleen is enlarged and, 
rarely, may rupture. There is no typical eruption but 
there may be a reddish mottling of the skin or petechial 
spots. The fever after lasting for about seven days 
falls by crisis in a few hours to normal or below. 
Accompanying the fall in temperature there is usually 
sweating and sometimes diarrhea. The patient rapidly 
regains strength but usually in a week the attack is re- 
peated. The relapse is, as a rule, shorter than the first 
paroxysm and several (three to five) of these may 



190 



FEVER NURSING. 



occur. In prQtracted cases convalescence is slow for 
the patient is likely to be much weakened. The disease 
is not a very fatal one and death, when it takes place, is 
usually due to complications. 



DAY OF 1 
DISEASE x 


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Clinical Chart of Relapsing Fever showing the febrile movement upon the 
fourteenth day. 

Complications. — Pneumonia is common ; gastric 
or intestinal hemorrhages are more rare. 

Prevention. — On the appearance of an epidemic 
measures should be taken to provide food for the suf- 
fering poor and to improve the sanitary condition of 
their surroundings in every way, especially by attention 
to the proper disposal of garbage. Although there is 



RELAPSING FEVER. 191 

no proof that the disease is transmitted by drinking 
water it is wise to boil all water used for this purpose. 
Relapsing fever does not spread readily under condi- 
tions of cleanliness and where ventilation is thorough, 
consequently plenty of fresh air should have access to 
the sick-room and when the disease has run its course 
the apartment as well as the clothing, bedding and 
utensils must undergo proper disinfection. 

Treatment. — The patient should be isolated and 
kept under strict quarantine. There is no drug which 
influences the disease, consequently the symptoms must 
be treated as they arise, according to general principles. 
The temperature may be controlled to some extent and 
the patient be made more comfortable by cold sponging. 
The diet should be fluid but in the afebrile intervals 
semi-solids may be allowed. When there is extreme 
prostration, heavy stimulation may be necessary. 

The nursing should be conducted according to the 
methods usual in febrile diseases. 

Dengue. 

Synonyms. — Breakbone fever; dandy fever. 

Definition. — Dengue is an acute, infectious febrile 
disease occurring in warm countries, characterized by 
pains in the muscles and joints and an erythematous 
skin eruption. 

Causation. — It occurs chiefly in hot climates and 
at the warmer and more moist seasons of the year. It 



i9 2 FEVER NURSING. 

is common in the East and West Indies, but is seldom 
seen in the United States, except along the coast of the 
Gulf of Mexico. It is believed to be caused by a 
microorganism which circulates in the blood and is 
transmitted through the bites of mosquitoes in the same 
manner as the infection of yellow fever. The infec- 
tion is probably not transmitted by contact with patients 
nor through clothing, etc. The disease is seldom fatal. 

Course and Symptoms. — The incubation period is 
from two to five days. The onset is marked by an 
acute chill, or in the case of children by a convulsion. 
A rise of temperature follows to 104 to 106 F. 
(40 to 41. i° C). The pulse is rapid and there are 
nausea, vomiting, and severe headache accompanied by 
pain and tenderness in the muscles of the trunk and 
limbs. The joints are hot, painful, red, tender and 
sometimes swollen. The pains in the joints and mus- 
cles, causing a stiff gait, have given rise to the name 
" dandy fever." The glands of the neck, axillae and 
groin may be swollen. There are flushing of the 
face, suffusion of the eyes, a coated tongue, highly 
colored and scanty urine and weakness and prostration. 
The eruption is a reddish blush which may itch and 
usually disappears on the third or fourth day; it is 
sometimes followed by desquamation. 

The rise in temperature lasts from three to five days 
and then falls by crisis accompanied by sweating and 
amelioration of all the symptoms. The temperature 



DENGUE. 193 

remains normal for several days and then the symptoms 
of the onset of the disease return, but with less severity ; 
during this recurrence various forms of skin eruptions 
may appear. The recurrence lasts from two to three 
days and a second crisis ensues after which convales- 
cence is established. 

The patient recovers strength slowly and is likely to 
be troubled by a persistence of the joint pains. 

Relapses are not infrequent but complications are 
rare. 

Prevention of the disease consists in destroying 
the mosquitoes, preventing their access to patients ill 
with the infection and protecting the healthy from 
their bites. Quarantine and disinfection in the light 
of our recently acquired knowledge of the mode of 
transmission of the contagium are unnecessary. 

Treatment. — The patient should be kept in bed 
while the symptoms are acute ; the medicinal treatment 
is wholly symptomatic. The pains may be relieved by 
the administration of various analgesic drugs and the 
joint inflammation lessened by applications of cold or 
heat. 

The Diet during the febrile stages should be of 
fluids alone ; during convalescence strength-giving 
foods should be given in easily digestible forms. 

The nursing should be carried on in accordance with 
general principles. 



CHAPTER VIII. 
THE EXANTHEMATA. 

Scarlet Fever: Smallpox: Chickenpox: Measles: German 
Measles: The Fourth Disease of Dukes: Epidemic Cere- 
brospinal Meningitis. * 

These diseases are known as the infectious exanthe- 
mata (from a Greek word meaning an eruption) and 
are characterized each by a typical rash upon the skin. 
They are all contagious and, except smallpox, are most 
frequently seen in children. 

Scarlet Fever. 

Synonym. — Scarlatina. 

Definition. — An acute, infectious fever character- 
ized by a scarlet rash upon the skin and usually accom- 
panied by sore-throat. 

Causation. — The disease is endemic and at times 
appears in epidemics of varying intensity. The ma- 
jority of cases occur in children under ten years of age. 
Nursing infants however seldom contract the disease; 
in pregnancy and after surgical operations susceptibility 
is increased. Certain individuals, some families and 
certain races, for instance the Japanese, seem unable to 
acquire the infection. Scarlet fever is due to a specific 

194 



SCARLET FEVER. 195 

organism which it is believed has been recently dis- 
covered. 

The infection is spread chiefly by the flakes of skin 
cast off by the patient and perhaps also by the means 
of his exhalations. The contagium clings persistently 
to clothing, books, toys and the like and is capable of 
transmitting the disease for months and even years. 
The physician or nurse may carry the infection to a 
third person. Epidemics are most frequent in the fall 
and winter. One attack usually protects against sub- 
sequent infections. It should be remembered that 
scarlatina is not a light form of scarlet fever, but that 
the two terms have exactly the same meaning. 

The eruption appears from twelve to thirty-six hours 
after the onset of the disease in the form of tiny red 
points; these may be so numerous and close together 
as to give the appearance of diffuse redness ; they may 
occur in irregular patches or they may be widely scat- 
tered. 

The rash appears first on the neck and shoulders 
and extends to the body, arms and legs. In one to four 
days it reaches its maximum and the skin becomes 
almost uniformly red and swollen. Drawing the finger 
nail over the skin leaves a whitish line which quickly 
disappears. The eruption is most marked upon the 
parts of the body which are kept warm. Upon the 
face the eruption is much less marked and usually ap- 
pears only on the forehead and cheeks, the skin about 



i9 6 FEVER NURSING. 

the nose and mouth remaining pale. The eruption re- 
mains at its height from one to three days and gradually 
disappears as the temperature approaches normal. 
The rash appears also upon the pharynx. 

Irregular eruptions are frequent and puzzling; they 
may appear only upon the trunk, the limbs or the face ; 
they may remain in the stage of diffuse patches; they 
may last but a few hours ; they may be entirely absent. 

Course and Symptoms. — The incubation period is 
usually one week, but may vary from one day to three 
weeks. Usually during this time there are no symp- 
toms except possibly slight sore-throat. The invasion 
is sudden with a chill or convulsion followed by a rise 
of temperature — io4°-io6° F. (40°-4i.i° C.) — rapid 
pulse, headache, vomiting and sore-throat. In from 
twelve to thirty-six hours the eruption appears and in 
about four days the entire skin is red, inflamed and 
tense ; the rash may be present upon the mucous mem- 
branes of the mouth and throat causing them to appear 
vividly red. The tongue is at first coated in the center 
and red and clean at its edges and tip. Through the 
coat the red tips of the papillae may be seen, giving the 
so-called " strawberry " appearance. In a few days 
the coat peels off leaving the tongue red and roughened 
— the " raspberry " tongue. The fever continues, with 
slight morning remissions, and falls gradually as the 
rash fades, reaching normal about the seventh day. 



SCARLET FEVER. 



197 



The sore-throat varies in intensity from a slight red- 
ness and swelling of the fauces and tonsils to a marked 
inflammation with a false membrane involving all the 
parts about the pharynx and accompanied by enlarge- 
ment of the glands under the jaw. 



^105 



107 



106 



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1 



1 



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Clinical Chart of Scarlet Fever. 

The spleen may be slightly enlarged. The urine pre- 
sents the characteristics usual in febrile disease and the 
existence of albuminuria is frequent. Daily examina- 
tions of the urine should be made and it is part of the 
nurse's duty to save specimens. 

As the temperature falls the symptoms ameliorate. 



198 FEVER NURSING. 

Desquamation, — As the fever and rash disappear the 
skin becomes dry and roughened and its upper layer 
loosens. This takes place first upon the chest, and 
gradually the dried flakes fall; the process continues 
from two to three weeks. Rarely the hair and nails are 
lost. 

Severe Forms of the Disease — The Anginose Form. 
— This is characterized by extreme severity of the 
throat inflammation. The pharynx and tonsils are 
swollen and red, and a membrane forms which may 
extend upward to the posterior nares or forward into 
the mouth; the lymph glands beneath the jaw and in 
the neck are swollen and necrosis of the tissues of the 
throat may follow ; with this there is a very foul odor. 
The inflammation may go on to involve the middle ear 
and more rarely the trachea and bronchi. The pros- 
tration is very marked. If the disease is not rapidly 
fatal abscesses frequently form in the tissues of the 
neck. Recovery is rare. 

The Hemorrhagic Form. — In this variety hemor- 
rhages may take place into the skin or mucous mem- 
branes, and may be evidenced by hemorrhagic spots 
upon the skin, nose-bleed or bloody urine. In this 
type death may occur as early as the third day. 

The Malignant Form. — In this the invasion is very 
severe and accompanied by marked cerebral symptoms 
— delirium or stupor; there may be suppression of 
urine; the temperature rises rapidly to a very high 



SCARLET FEVER. 199 

point — 108 F. (42.2 ° C.) — and death is likely to 
supervene even before the rash is developed. 

Complications and Sequelae. — The most impor- 
tant of these are nephritis and inflammation of the 
middle ear. The nephritis varies in intensity from 
slight albuminuria and hardly noticeable edema of the 
feet and ankles to severe kidney inflammation with 
diminished or even suppressed urine. In the intense 
cases there are considerable albumin, numerous casts 
and perhaps blood in the urine, marked dropsy, constant 
vomiting and uremic convulsions; some of these cases 
die or go on to permanent chronic nephritis, but prompt 
and proper treatment may result in the disappearance 
of the symptoms and the return of the kidneys to a 
healthy condition. 

Ear Complications are frequent and are due to an 
extension of the throat inflammation through the 
eustachian tubes. The otitis causes severe pain which 
persists until the drum membrane ruptures or is punc- 
tured, allowing the escape of the pus. The ear inflam- 
mation may extend to within the skull and cause various 
meningeal and brain complications. Deafness is not 
an uncommon result. 

Joint Complications with all the symptoms of acute 
articular rheumatism may occur. These usually appear 
after the temperature has fallen to normal, but may 
show themselves during the febrile movement. 



2oo. FEVER NURSING. 

Heart Complications are not rare, and often result in 
a permanent affection of one or more of the valves of 
that organ. Inflammations of the pericardium and of 
the heart muscle may occur as well. 

Pleurisy and Pneumonia are infrequently associated 
with scarlatina. 

Chorea sometimes complicates the disease and is most 
likely to occur in the cases followed by endocarditis 
and arthritis. 

Throat Complications. — These have been considered 
above (see the anginose form of scarlet fever, p. 198). 

Prevention. — The patient should be immediately 
isolated and other children of the family removed. 
These latter should be kept from association with other 
children for ten days at least in order that the disease 
may develop if they have been exposed ; careful watch 
should be kept of their throats. 

The hygiene of the sick-room should be the same as 
that in cases of smallpox (see p. 210) and all clothing 
dressings, utensils and discharges should be cared for 
in exactly the same manner. Free ventilation of the 
sick-room is important and a temperature of 65 ° to 
70 ° F. (18 to 20 C.) should be maintained. The pa- 
tient must be kept in bed, even in the mildest cases, and 
lightly covered, but should be sedulously guarded from 
draughts. Both the physician and the nurse should 
wear a cap and gown over their ordinary clothing when 
in the patient's presence and the former upon leaving 



SCARLET FEVER. 201 

the sick-room should pass directly into the open air. 
A sheet wet with five per cent, carbolic acid solution 
and suspended before the door of the apartment is an 
excellent measure. 

The quarantine should be continued for from six to 
eight weeks — longer if desquamation has not ceased 
during this period — and when raised both patient and 
nurse should bathe as after smallpox, and the apartment 
with its contents should be disinfected after the usual 
manner and thoroughly aired. Books, toys, and the 
like with which the patient has come in contact should 
be burned. 

Treatment. — The general treatment of the disease 
is symptomatic. Considerable research has of late been 
carried out along the lines of serum treatment, but so 
far the results have been inconclusive. 

The patient should receive two lukewarm sponge 
baths daily and if there is distressing itching and burn- 
ing of the skin he may be lightly smeared with albolene, 
olive oil or cacao butter. This should be done twice 
a day when desquamation has commenced, for it is 
not only grateful to the patient, but also prevents the 
dissemination of the flakes of skin. 

Copious and frequent draughts of water, plain or 
carbonated, should be urged upon the patient and in 
cases with very high temperature two cool baths — 90 
to yo° F. (32.2 to 21.1 C.) — should be given. The 
mouth, throat and nose should be subjected to frequent 
H 



202 FEVER NURSING. 

spraying and cleansing with Dobell's or other alkaline 
solution, for by this means ear involvement may be in 
great measure prevented. The urine must be examined 
daily and the nurse should prepare a specimen each 
day before the physician's visit. 

The Diet. — During the febrile stage the diet 
should be of fluids alone (see general principles of 
feeding in fevers, p. 64), but when the temperature 
has become normal, a gradual return to solid diet is 
advisable. In cases with albuminuria meats must not 
be allowed as long as this symptom persists. 

The nursing should be carried on in accordance with 
the principles laid down for the infectious diseases. 

Smallpox. 

Synonym. — Variola. 

Definition. — Smallpox, as distinguished from 
grand pox (syphilis), is an acute infectious disease 
characterized by a typical eruption appearing first in the 
form of macules or spots, and becoming successively 
papules, vesicles and pustules, upon the last of which 
crusts form which drop off and leave scars. 

Causation. — The disease has existed as an epi- 
demic since many centuries before Christ and until the 
introduction of vaccination was so universal a scourge 
that persons who showed no pock-marks were rarely 
seen. Its specific cause is believed to be a recently 
discovered microorganism. Smallpox is contagious 



SMALLPOX. 203 

throughout its entire course after the eruption has ap- 
peared and a few moments of association with an in- 
dividual suffering from it are a sufficiently long time to 
contract the disease. The contagion may be carried 
great distances in clothing, etc., and the pulverized dry 
crusts retain the power of transmitting the infection for 
several years. Inoculation from the contents of the 
vesicles and pustules, the scabs and the blood is pos- 
sible. It is believed that the infection enters the body 
with the inspired air, and it probably exists in the secre- 
tions and excretions, and in the exhalations from lungs 
and skin. The severest type of smallpox may be con- 
tracted from a very mild case. The disease respects 
neither race, age nor sex and very few unvaccinated 
persons escape after exposure. Usually, but not 
always, one attack precludes the possibility of a second 
infection. Inasmuch as this disease occurs almost 
exclusively in unvaccinated persons it may be said to 
be a disease of choice. 

The Eruption appears about the third day, first upon 
the face and scalp, and spreads, finally involving most 
of the skin and mucous membranes. At first it is in the 
form of round, red spots, which by the second day 
become slightly elevated; by the sixth day these have 
become vesicles with depressed centers (umbilicated) 
and by the eighth day they have changed into pustules. 
As this last transition is taking place the skin and 
mucous membranes become swollen and inflamed. If 



204 FEVER NURSING. 

the pustules extend into the deeper layers of the skin, 
scars (pock-marks) result. 

The eruption appears upon the tongue and the lining 
of the mouth and throat, rarely it extends into the 
esophagus and stomach ; it may show itself in the rec- 
tum. In the larynx it is accompanied by inflammation 
and sometimes by edema. Rarely the eruption appears 
first upon the mucous membianes. The above is a de- 
scription of the discrete form of the eruption; in the 
rarer types of the disease the rash may undergo various 
modifications. 

Course and Symptoms. — The incubation period is 
usually from ten to fifteen days. The invasion is sud- 
den with a distinct chill or chilly sensations followed by 
a rapid rise of temperature — 103 to 106 F. (39.5 to 
41. 1 ° C). The pulse is rapid and full (100-120) the 
respirations are accelerated, the tongue is coated and 
there may be vomiting, convulsions or delirium. There 
are severe headache and general bodily pains. A pro- 
nounced aching pain in the small of the back is so 
typical as to be an aid in distinguishing smallpox from 
other eruptive fevers. A feeling as of shot under the 
skin of the palm at the base of the thumb, due to the 
undeveloped eruption, is another diagnostic point. 
There may be sore- throat and conjunctivitis; there is 
usually enlargement of the spleen; bleeding from the 
skin and mucous membranes are rarer symptoms. 



SMALLPOX. 



205 



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petechiae, streaks or diffuse blushes and reddish, brown- 
ish or purple in color. These become paler on pres- 
sure. They are not raised and may occur on any part 
of the body, but are most frequently seen on the inner 



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Clinical Chart of Smallpox showing fall of temperature upon the appearance 
of the eruption and its rise upon the incidence of the stage of pustulation. 

sides of the thighs and arms, the groins, upper abdomen 
and chest. About the third day the typical eruption 
appears and in a favorable case the temperature falls, 
the symptoms subside, the eruption passes through its 



2o6 FEVER NURSING. 

various stages, finally scabs form which drop off and 
leave scars behind. The healing of the eruption may 
be accompanied by troublesome itching. 

The Confluent Form of smallpox follows a shorter 
period of incubation and is ushered in by severe symp- 
toms; the temperature may rise as high as no° F. 
(43.3 C), and as the eruption appears there is very 
little amelioration of the patient's condition. The 
papules are large and when they become pustules they 
run together so that the skin is infiltrated with pus. 
The confluency may be confined to the face, hands and 
feet, or it may involve the entire surface of the body. 
The mucous membranes are swollen, much inflamed 
and may become gangrenous. With this inflammation 
all the symptoms of sepsis are present — rapid, feeble 
pulse, marked nervous symptoms and great prostration. 
An intolerable odor rises from the patient and the pic- 
ture presented by him is perhaps more horrible than 
that in any other disease. The formation of scabs in 
this variety of smallpox may take three or four weeks. 

The Malignant Form, — In this type of the disease 
the temperature may never be high, but the consti- 
tutional symptoms — especially those referable to the 
nervous system — and the prostration are very marked. 
This form of smallpox is usually fatal and death may 
take place before the rash — which is likely to be typical 
— appears. 



SMALLPOX. 207 

The Hemorrhagic Form is characterized by the effus- 
ion of blood into the skin and the pustules, and bleeding 
from the mouth, nose, lungs, stomach or any of the 
mucous membranes. This type as a rule is fatal, death 
occurring sometimes as early as the third or fourth 
day. Neither this nor the malignant variety is often 
seen in persons who have been vaccinated. 

Varioloid is true smallpox occurring in individuals 
who have been vaccinated and is a shorter and milder 
disease than the unmodified variety. The eruption is 
not extensive, the pocks are small and some of the 
vesicles may dry without becoming pustules; there is 
rarely any scarring. The initial symptoms are not 
severe with the exception of the pain in the back, and 
when the rash appears, which it usually does about the 
third or fourth day, the constitutional disturbance sub- 
sides. The eruption drys and the scabs fall from five 
to seven days after the appearance of the eruption. 

The severe types of smallpox may be contracted by 
unvaccinated persons from the mild form. 

Prevention. — The introduction of vaccination by 
Jenner at the close of the eighteenth century has caused 
smallpox to become a rare disease in communities where 
the measure is systematically practiced, and too great 
insistence cannot be laid upon the necessity for the 
routine performance of the operation. All children 
should be vaccinated at from three to five months of 
age, every seven years thereafter and in the intervals 



208 FEVER NURSING. 

whenever the disease is prevalent; at such times one 
should never be satisfied with an unsuccessful attempt. 
Vaccination does not always protect, but the disease 
as it occurs in those who have undergone the operation 
is very rarely severe. 

Vaccination is performed as follows: The site 
selected is, in the case of boys, the outer side of the 
arm at the junction of its upper and middle thirds. In 
vaccinating girls in the upper walks of life it is pre- 
ferable to use the outer side of the calf. Human lymph 
or calf lymph may be used, but the latter is preferable. 
The skin over the part chosen should be sterilized by 
washing with soap and water, alcohol and I to 5,000 
mercury bichlorid solution, wiped with sterile water and 
allowed to dry. Then with a needle which has been 
sterilized by heating in a gas flame a surface one eighth 
to one fourth of an inch in diameter is lightly scratched, 
care being taken not to draw blood, but merely to 
remove the upper layers of the integument. A slight 
exudation of serum will follow this procedure and into 
this the vaccine should be rubbed for several moments. 
The surface should be allowed to dry and then dressed 
lightly with a compress of sterile gauze. The various 
shields sold to cover vaccination wounds should not be 
used. Different makers supply dried vaccine upon 
quills or ivory points. When from a reputable firm 
these may be used. The health boards of certain cities 
furnish calf lymph put up in glass tubes and packed 



SMALLPOX. 209 

with a needle, a bit of wood and full directions for the 
performance of the operation. When available such an 
outfit should be employed. 

The train of symptoms following vaccination is 
termed vaccinia and differs in different individuals. If 
the procedure is successful and the vaccination " takes " 
a papule appears about the third day; on the fifth to 
the seventh day this becomes a vesicle surrounded by a 
red area which about the eighth day becomes the seat 
of a suppurative process and is painful and tender. 
From this time the inflammation gradually subsides and 
about the twenty-first day the scab falls, leaving the 
familiar whitish scar. Protection is believed to be 
effected about the thirteenth day. 

About the third day after vaccination there may be 
a rise of temperature which may last a week or more; 
with this there are headache, gastric disturbances, rest- 
lessness, etc., but usually these symptoms are of little 
moment and require no special treatment. Frequently 
there is enlargement and tenderness of the axillary or 
inguinal glands, depending upon the site of the inocu- 
lation. 

Generalized Vaccinia is rare but may manifest itself 
as a pustular rash on different parts of the body, ap- 
pearing on the eighth to the tenth day ; the pustules are 
most abundant upon the vaccinated limb and may con- 
tinue to appear for several weeks. The disease may 
prove fatal in children. 



210 FEVER NURSING. 

Complications of Vaccination. — Syphilis may follow 
if infected humanized lymph be used, and tetanus has 
been known to result from the employment of con- 
taminated bovine virus. Erysipelas and septicemia are 
possible complications but proper antiseptic precau- 
tions will prevent their occurrence. 

When a case of smallpox appears in the community, 
every person who has recently associated with the in- 
dividual should immediately be vaccinated, no matter 
how short a time previously this has been done. It is 
also wise to vaccinate the patient, though this seldom 
results in any modification of the disease. 

The patient should be subjected to the strictest isola- 
tion, no one being allowed to approach him but his 
nurse and physician. It is best to procure a nurse who 
has had the disease, but if this is impossible, one who 
has recently been vaccinated successfully. The nurse 
and physician should wear caps of oiled silk or rubber 
and linen or cotton gowns enveloping the whole figure 
when in the sick-room. Their visits to the patient 
should be as brief as possible. The room in which 
the patient is confined should be emptied of all draper- 
ies and superfluous furniture and should be thoroughly 
ventilated at all times. An apartment with a fire-place 
is best, for in addition to improving ventilation this 
offers a place for burning all contaminated substances. 
All the patient's excreta should be disinfected as de- 
scribed in Chapter IV. and it is wise to suspend before 



SMALLPOX. 211 

the door a sheet, wet with five per cent, carbolic acid 
solution, just outside which disinfectants should be 
kept in which physician and nurse may wash hands and 
face after leaving the patient. All washable clothing 
both of nurse and patient should be soaked in a disin- 
fecting solution for from six to ten hours before it is 
taken to the laundry and then it should be thoroughly 
boiled. After the patient's recovery or death every- 
thing with which he has come in contact should be 
burned. If there is a disinfecting plant available the 
mattresses and bedding may be disinfected by steam 
under pressure, but either this process or burning is 
absolutely necessary. When the quarantine is raised, 
which must not be done until the last scab has fallen, 
the patient and nurse should bathe in a I to 2,000 mer- 
cury bichlorid solution, carefully protecting the eyes; 
the hair should be shampooed and clean clothing put on 
in another room. 

If the patient dies the body should be wrapped in 
a sheet wet with 1 to 2,000 mercury bichlorid solution, 
sealed in a metal coffin and cremated or buried as soon 
as possible. 

The apartment should be disinfected according to the 
usual methods and thoroughly aired. 

Treatment. — The treatment of the disease is 
symptomatic. The patient's hair should be cut short, 
and the tendency to pitting may be lessened if strict 
attention is paid to cleanliness, and if the patient wears, 



212 FEVER NURSING. 

to keep him from scratching, gloves and a gauze mask 
moistened with either two per cent, carbolic acid or a 
saturated boric acid solution. Frequent immersions in 
warm water or cleansing with hydrogen peroxid solu- 
tion will aid in keeping the skin clean and free from 
pus. A thin ointment of ichthyol of 10% strength is 
very soothing to the face. 

The feeding and nursing, on points other than those 
discussed above, should be conducted according to gen- 
eral principles. 

Chicken Pox. 

Synonym. — Varicella. 

Definition. — An acute, infectious, febrile disease 
of mild type characterized by a vesicular eruption. 

Causation. — The disease is sporadic and occurs also 
at times in epidemics. It is essentially a disease of 
children and but very rarely is seen in the adult. It 
occurs in all climates and at all seasons. Its specific 
cause has not yet been discovered but is probably a 
bacterium. The contagium is given off from the pa- 
tient and it probably effects entrance to the body with 
the inspired air. One attack usually, but not invari- 
ably, confers immunity. 

The Eruption as a rule appears on the first day of 
the disease, first upon the face and scalp, later upon 
the neck, body and limbs. The rash begins as a 
rounded red spot which quickly becomes a papule and 
reaches the vesicular stage within a few hours. The 



CHICKEN POX. 213 

vesicles vary in size from one sixteenth to one half inch 
in diameter. Occasionally a few vesicles go on to the 
pustular form. There is no umbilication and when 
pricked the vesicle collapses entirely, which is not the 
case in smallpox. The eruption lasts from two to five 
days, when the vesicles dry, from crusts and soon fall, 
leaving no scar. The pustules may leave a slight de- 
pression which is almost never permanent. Successive 
crops appear and we may see the eruption in all stages 
at the same time. If the vesicles are scratched they 
may leave cicatrices. The eruption may appear on the 
mouth and throat. 

Course and Symptoms. — The incubation period 
is from ten to fifteen days ; the period of invasion lasts 
one or two days with slight fever and malaise. The 
onset is marked by chilly feelings, seldom by convul- 
sions, moderate fever (ioo° to 102 F. — 37.8 to 
38.9 C), general pains, nausea and prostration. The 
eruption appears within twenty-four hours and the 
fever and other symptoms rarely last more than two or 
three days. 

Complications are infrequent. 

Prevention. — The patient should be isolated until 
the last crust has fallen; then the sick-room may be 
disinfected but cleaning and airing are usually suffi- 
cient. 

Treatment is usually unnecessary except in so far 
as cleanliness is concerned. The large vesicles may be 



214 FEVER NURSING. 

opened and washed with boric acid solution ; the itching 
may be relieved by the application of olive oil which 
will also be found useful in loosening the crusts. It 
may be necessary to mitten the patient's hands to pre- 
vent scratching. In any case the finger nails should 
be kept short and frequently cleansed with soap, water 
and a brush. 

During the febrile stage, fluid diet is to be preferred, 
but as soon as the temperature reaches normal easily 
digested solids may be given. 

Nursing should be conducted in accordance with 
general principles. 

Measles. 

Synonyms. — Rubeola ; morbilli. 

Definition. — Measles is an acute, infectious fever 
characterized by congestion of the upper air passages 
and conjunctivae and accompanied by an eruption of 
maculo-papular form. 

Causation. — The disease is commonly endemic, 
epidemics appearing at intervals. It usually appears in 
children, but adults often contract it; it is most preva- 
lent in the cold months. Its specific cause is a germ 
which has not yet been discovered. The infection is 
spread by contact, by the breath, the secretions, espe- 
cially those of the nose, by articles which have come in 
contact with sufferers from the disease and through a 
third person. One attack usually, but by no means 



MEASLES. 215 

always, confers immunity; several attacks in the same 
individual have been observed. 

The Eruption appears about the fourth day, is mac- 
ulo-papular in form and the spots, at first roundish, 
rose-colored, slightly elevated papules, tend to coalesce 
into a crescentic shape. The rash appears first on the 
face and mucous membranes, then upon the body and 
last upon the extremities ; it is fully developed in from 
two to four days and then gradually fades. In from 
ten to fourteen days fine desquamation takes place. 
Rarely the rash may be vesicular or hemorrhagic. 

A day or two before the eruption small red spots 
from the size of a pin-head to that of a split pea appear 
on the lining of the cheeks and mouth. At the center 
of these is a bluish-white spot which may be made out 
with the aid of a strong light. These are known as 
Koplik's spots and are a certain and early diagnostic 
sign of the disease. 

Course and Symptoms. — The incubation period is 
from ten to fourteen days; the period of invasion 
usually lasts four days. The disease is ushered in by 
chills or convulsions followed by a rise in temperature 
to 105 to 106 F. (40.5 to 41. i° C), headache, pros- 
tration, rapid pulse, vomiting and at times diarrhea. 
There are usually conjunctivitis and rhinitis; the 
tongue is coated and the glands of the neck may be 
swollen. During the height of the fever stupor or 
delirium may be present. In from ten to fourteen days 



2l6 



FEVER NURSING. 



the eruption disappears, the fever subsides and con- 
valescence is established. 

The Hemorrhagic Type {Black Measles) may occur 
during epidemics in institutions where many children 
are congregated or among savage races attacked for the 
first time. The eruption is dark and bleeding takes 
place into the skin and from the mucous membranes; 



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Clinical Chart of Measles showing defervescence by lysis beginning when 
the eruption is fully developed. 

the nervous symptoms are marked, the temperature 
high and the prostration extreme. Gangrene of the 
face sometimes occurs as a complication. This form 
of the disease is very fatal. 



MEASLES. 217 

Complications. — Convalescence may be inter- 
rupted by a continuance of the conjunctivitis, by 
pharyngitis, inflammations of the ear or of the lymph 
glands, bronchitis and, most important of all, broncho- 
pneumonia. "Whooping-cough or diphtheria may be 
associated with the disease. The inflamed glands offer 
a fertile field for infection by the tubercle bacillus and 
such an infection may be followed by acute miliary 
tuberculosis. 

Prevention. — The measures to be taken to prevent 
the spread of the disease are the same as those appli- 
cable in scarlatina, but are less likely to be successful, 
for the contagium, although its life is shorter, seems to 
be much more easily diffusible. The patient should be 
isolated in an airy room, protected from draughts and 
not allowed to associate with others until at least two 
weeks have elapsed since the onset. Many parents en- 
courage their children to expose themselves on the prin- 
ciple that every one must contract the disease, but this 
is little less than criminal. 

All discharges, dressings, clothing, etc., should be 
disinfected according to the usual methods. 

Treatment — The patient should be kept in bed in 
a dark room while the temperature is elevated and 
should be given at least one sponge bath daily with cool 
water. A disinfecting bath for both patient and nurse 
at the termination of the period of isolation is an essen- 
tial. The eyes should receive careful attention; a few 
15 



218 FEVER NURSING. 

drops of a saturated solution of boric acid should be 
dropped into them every four hours and the nose should 
be kept clean by means of an antiseptic such as Dobell's 
solution. During desquamation the skin should be 
anointed with albolene or cacao butter. The treatment 
in other respects consists in the combating of the symp- 
toms as they arise. 

The Diet during the febrile movement should be 
entirely fluid — milk, broths and the like — and the drink- 
ing of cool water is to be encouraged. As convales- 
cence progresses a gradual return to solid diet is proper. 

The nursing applicable to the other infectious ex- 
anthemata is equally suited to measles. 

German Measles. 

Synonyms. — Roseola; Rubella; Rotheln. 

Definition. — An acute, infectious febrile disease, 
accompanied by a maculo-papular eruption and enlarge- 
ment of the lymph-glands of the neck. Roseola may 
resemble measles and scarlet fever in its symptoms, but 
it is a distinct disease. 

Causation. — The disease occurs most frequently 
in children, although it may be contracted by adults; 
it is most commonly observed during the cold months. 
The specific cause of the disease has not been dis- 
covered, but the infection seems to be given off in 
the expired air and from the skin. Usually one attack 
gives protection against further infection. 



GERMAN MEASLES. 219 

The Eruption appears upon the first or second day of 
the disease, first upon the forehead and spreads quickly 
over the face, neck, body and finally the extremities. It 
is in the form of round pinkish points one sixteenth to 
one fourth of an inch in diameter, slightly elevated and, 
at first, disappears on pressure. The spots may be 
aggregated into blotches resembling the rash of measles 
but are less frequently crescent-shaped, or into a diffuse 
redness resembling scarlet fever. The rash lasts from 
one to seven days and may fade in one place before 
appearing in another. Occasionally some of the 
papules may turn into vesicles or pustules. Desquama- 
tion seldom takes place. 

Course and Symptoms. — The incubation period is 
from one to three weeks ; its average is about ten days. 
The invasion resembles that of measles, but is less 
severe; the appearance of the rash may be the first 
symptom. The onset is marked by chilly feelings, 
slight fever, headache, nausea, catarrhal inflammation 
of the mucous membranes lining nose, throat and eyes, 
and swelling of the lymph-glands of the neck, rarely of 
those of the groins and axillae. When the rash is fully 
developed the fever may reach 102 to 103 F. (38.9 
to 39-5° C.), an< 3 all the symptoms are accentuated. 
After a few days the rash fades and the symptoms dis- 
appear. 

Complications and relapses are rare. 



220 FEVER NURSING. 

Prevention. — The patient should be kept to him- 
self in a darkened room, if the eyes are affected, for 
ten days or two weeks, but the thorough disinfection 
necessary during and after measles and scarlet fever is 
not required. 

Treatment is usually unnecessary, but the patient 
should be kept in bed if possible. 

The Diet should be regulated in accordance with 
the patient's condition; the nursing may be conducted 
according to general rules. 

The " Fourth Disease " of Dukes. 

This is considered by Dukes to be an independent 
disease of mild character which simulates mild scarla- 
tina, but differs from it in that its incubation period is 
much longer, being from nine to twenty-one days, and 
in its lack of prodromal symptoms. The eruption re- 
sembles that of scarlatina except that it begins upon the 
face ; it is usually followed by profuse desquamation. 

Many authorities doubt the existence of this as a 
separate disease and it is certain that, before its identity 
can be established beyond question, further study must 
be made of German measles. 

No especial consideration of the treatment or nursing 
of " Fourth Disease " is necessary. 

Epidemic Cerebrospinal Meningitis. 

Synonyms. — Cerebrospinal fever ; spotted fever ; 
malignant purpuric fever; petechial fever. 



EPIDEMIC CEREBROSPINAL MENINGITIS. 221 

Definition.— An acute infectious fever appearing 
usually in epidemics and characterized by inflammation 
of the membranes of the brain and spinal cord and com- 
monly by an eruption. 

Causation. — The disease is most likely to appear 
in crowded localities amid unsanitary surroundings and 
is most often seen in the cold months. Children are 
more prone to contract the infection than grown per- 
sons. The specific cause of this variety of meningitis 
is a bacillus which reaches the membranes of the brain 
and spinal cord through the nose or having been 
breathed into the lungs finds access to the blood-stream 
and is carried by this medium. The contagion is prob- 
ably not transmitted by the excreta or from one person 
to another. 

Course and Symptoms. — The period of incubation 
is not certainly known. The onset is sudden and ac- 
companied by a chill followed by fever, severe pain in 
the back of the head, projectile vomiting, soreness at 
the back of the neck and inclination to bend the head 
backward. There are various symptoms referable to 
the eyes; dread of light, squint, falling of the upper 
lid, unequal pupils and movements of the eyeball from 
side to side. Sounds annoy the patient. There is 
often nose-bleed, and fever sores upon the lips are fre- 
quent. Delirium soon appears. 

The temperature curve shows great irregularity, 
being high at times, then dropping to normal only to 



222 FEVER NURSING. 

rise suddenly again. The typical pulse is slow in com- 
parison with the height of the fever, but some patients 
exhibit a rapid heart action. 

Small petechiae or larger purpuric spots may appear 
upon the body and there may be erythematous patches. 
During the disease there are likely to be convulsive 
movements of the extremities, and the legs are usually 
drawn up. The head is forced into the pillow, and 
the facial expression is typical — the risus sardonicus — 
the forehead is wrinkled and the teeth are exposed by 
the drawing outward of the corners of the mouth. 
Children are likely to make an outcry typical of the 
disease. It is a single, high shrill cry and when once 
heard is easily recognized. 

The patient becomes rapidly emaciated and bed-sores 
are almost certain to ensue. The bowels are usually 
constipated and in the late stages there may be inability 
to swallow, in which case food must be given through a 
tube passed into the stomach through the nostril, or by 
rectum. As the disease progresses the nervous irri- 
tability ceases and the patient becomes stuporous or 
even comatose and there is incontinence of urine and 
feces. 

In patients who recover the fever lasts several weeks 
and then gradually falls ; as this takes place the symp- 
toms slowly ameliorate. Relapses sometimes occur. 

Convalescence is protracted. 



EPIDEMIC CEREBROSPINAL MENINGITIS. 223 

Different varieties of the disease may occur as fol- 
lows : 

(a) The Mild Type with dizziness, headache, stiff- 
ness of the neck, and low temperature. 

(b) The Intermittent Type in which the symptoms 
improve at intervals of a few days but recur. 

(c) The Malignant Type in which hemorrhages take 
place into the skin, the symptoms are intense and death 
takes place within a few hours. 

(d) The Chronic Type which may last for several 
months with severe symptoms and marked emaciation. 

Complications. — Pneumonia is the most common 
of these. Patients may recover with deafness or 
blindness and in children physical and mental develop- 
ment are frequently interfered with. 

Treatment. — Isolation in a quiet, darkened room 
is necessary. The head must be shorn and an ice cap 
applied, and cold applications may be made to the spine. 
The delirium and convulsions should be controlled by 
sedatives and the temperature by cold sponging. 

During convalescence the different tonics are indi- 
cated. 

The Diet. — The nurse should do her utmost to 
maintain the nutrition of the patient by the frequent 
administration of nourishing foods in fluid or semi- 
fluid form. When swallowing has become impossible 
feeding by rectum and by gavage must be employed. 
During the stage of convalescence it is necessary that 



224 FEVER NURSING. 

the patient should receive liberal feeding in order that 
he may regain his strength as rapidly as possible. 

The nursing otherwise should be conducted along the 
usual lines. 



CHAPTER IX. 

THERMIC FEVER. 
Heat Exhaustion: Insolation. 

Synonyms. — Sun-stroke; heat-stroke; heat prostra- 
tion. 

Definition. — A condition of prostration caused by 
exposure to intense heat. 

Causation. — Thermic fever is most common in 
adult males, probably because of their greater liability 
to exposure and tendency to alcoholic habits. It also 
occurs frequently in infants. It is predisposed to by 
over-indulgence in exercise, food and alcohol. Sol- 
diers on the march, stokers in the fire-rooms of steam- 
ers, bakers and others whose occupations necessitate 
exposure to the sun or to extremes of artificial heat, are 
frequent sufferers. 

Heat Exhaustion. 
Course and Symptoms. — This affection is the re- 
sult of continued exposure to high temperatures espe- 
cially when combined with muscular exertion and is 
characterized by prostration, collapse, subnormal tem- 
perature— 95° to 97 F. (35 to 36.1 C.)— and small, 
quick pulse ; the surface of the body is usually cool and 
in severe cases there may be delirium. 

225 



226 FEVER NURSING. 

Insolation. 

Course and Symptoms. — In the milder type of this 
affection the onset is marked by headache, dizziness, 
prostration and possibly nausea and vomiting. Un- 
consciousness may follow. The skin is flushed, hot 
and dry, the temperature ranges from 104 to 112 F. 
(40 to 44 C.) or even higher, the pulse is rapid and 
full, the breathing may be difficult and stertorous ; the 
pupils usually are contracted. In the fatal cases the 
unconsciousness becomes more profound, the heart 
weaker, the respiration rapid and shallow and death 
may supervene within from twelve to thirty-six hours. 
In favorable cases a fall in temperature is accompanied 
by a remission of the other symptoms. Complete re- 
covery may ensue or the patient may be left "with ner- 
vous and mental disturbances varying from simple loss 
of memory to insanity. A common sequel is inability 
to bear even slight degrees of heat; individuals with 
this idiosyncrasy have been known to become very 
uncomfortable at as low a temperature as 8o° F. 
(26.7 C). 

In marked cases the patient may die suddenly or 
within a short time with all the symptoms of heart fail- 
ure such as rapid almost imperceptible pulse, extreme 
dyspnea, and unconsciousness. 

Prevention consists in the avoidance of extreme 
heat, abstinence from alcohol, over-eating and over- 
work ; plenty of water should be drunk, frequent baths 
are advisable and the clothing should be light. 



THERMIC FEVER. 227 

The Treatment of Heat Exhaustion consists in 
rest in a cool place and stimulation. 

The Treatment of Thermic Fever consists in en- 
deavors to lower the bodily temperature as rapidly as 
possible. If a bath tub is available the patient should 
be immersed in cool water and rubbed vigorously with 
lumps of ice in the hands of at least two attendants. 
If no tub is at hand, the patient should be placed in the 
shade and cool water dashed upon him. Syncope may 
be controlled by hypodermatic injections of alcohol 
and such other stimulants as ether and ammonia may 
be given by the same means; artificial respiration may 
be necessary. If tubbing is impossible ice water ene- 
mata may accomplish good results ; spinkle baths from 
a watering pot, held at a height, or from a hose seem 
to have a good effect, probably from the stimulation 
caused by the impact of the water against the body. 

The temperature should be taken at frequent in- 
tervals and when it has reached 102 F. (38.9 C.) the 
hydriatic measures should be stopped, for otherwise the 
temperature is likely to fall to a subnormal level and 
collapse may result. The patient should now be put 
to bed, given a cathartic and catheterized if necessary; 
he should remain in bed and on a light diet for a few 
days. Subsequent rises of temperature may be con- 
trolled by cold sponging or tub baths if necessary; 
otherwise no departure from the general principles of 
nursing in febrile conditions need be made. 



INDEX. 



Abdominal typhus, see Enteric 

Fever 
Acute febrile jaundice, see Weil's 
Disease 
miliary tuberculosis, 132 
tuberculosis, see Acute Mil- 
iary Tuberculosis 
Antipyretic drugs in fever, 44 
Antitoxin injections in diph- 
theria, 159 

Baths, bed or slush, 47 

in enteric fever, 104 ff. 
sheet, 50 
sponge, 48 
sprinkle, 49 
towel, 50 
tub, 44 
Bed and bed clothing in febrile 

disease, 74, 75 
Bed-sores, prevention and treat- 
ment of, 54 
Beverages in febrile disease, 67 
Black death, see Typhus Fever 
Blood poisoning, see Septicemia 
Brand Bath, so-called. 104 
Breakbone fever, see Dengue 
Bubonic plague, 17S 

causation of, 179 
course and symptoms 

of, 179 
definition of. 17S 
prevention of, 180 
treatment of. 180 

Camp fever, see Typhus Fever 
Catheterization, directions for, 
59 



Cellulitis, 16S 

Centigrade and Fahrenheit, rule 
for reducing the one into 
the other, 30 
scale of thermometry 29 
Cerebrospinal fever, see Menin- 
gitis. Epidemic Cerebrospinal 
Chicken pox, 212 

causation of, 212 
course and symptoms 

of, 213 
definition of, 212 
eruption of, 212 
prevention oi, 213 
treatment of. 213 
Child-bed fever, see Puerperal 

Fever 
Chills and fever, see Malarial 

Fever 

Circulatory system, symptoms of 

fever referable to. _: 

treatment of symptoms 

of fever referable to, 

. 57 

Consumption, see Tuberculosis, 

Chronic Pulmonary 
Convalescence, diet in, 68 
Convulsions in fever, treatment 

of, 60 
Cream of tartar lemonade, 5S 
Crisis in fever, 12 
Currie-Tiirgensen Bath, 104 

Dandy fever, see Dengue 
Defervescence, 11 
Delirium in fever, 24 
Dengue, 191 

causation of, 191 



229 



230 



INDEX. 



Dengue, course and symptoms of, 
192 
definition of, 191 
diet in, 193 
prevention of, 193 
treatment of, 193 
Diet in convalescence, 68 
in febrile disease, 64 
list for convalescents, 69 
Digestion, symptoms of fever 

referable to organs of, 19 
Digestive organs, treatment of 
symptoms of fever referable 
to, 56 
Diphtheria, 151 

causation of, 151 
complications of, 154 
course and symptoms of, 152 
culture taking from throat 

in, technique of, 155 
definition of, 151 
diet in, 162 
false, 162 
laryngeal, 154 
malignant, 153 
nasal, 154 

prevention of, 156 ff. 
treatment of, 158 ff. 
Disinfectants, 79 ff. 
Disinfection during and after 
febrile diseases, 79 ff. 
of excreta, etc., 84 ff. 
of rooms, bedding, etc., 

technique of, 81 ff. 
of waterclosets, drains, sinks 
and privies, 86 
Dizziness in fever, 23 
Drains, Disinfection of, 86 

Ears, treatment of symptoms 

referable to in fever, 63 
Enemata, ice- water, 52 
Enteric fever, 87 

afebrile, 95 

baths in, 104 ff. 



Enteric fever, causation of, 87 ff. 
clinical chart of, 93 
complications of, 100 
convalescence in, 99 
course of, 91 
definition of, 87 
diet in, 108 
eruption of, 96 
face in, 95 
in children, 101 
in old persons, 102 
nursing in, no 
prevention of, 102, 103 
relapses in, 95 
symptoms of, 95 
temperature in, 91, 92 
the onset of, 89 
tongue in, 96 
treatment of, 104 
treatment of complica- 
tions of, 107, 108 
typical case of, 96 
Epidemic catarrhal fever, see In- 
fluenza 
Erysipelas, 166 

causation of, 167 
complications of, 169 
cutaneous, 167 
definition of, 166 
diet in, 170 
phlegmonous, 168 
treatment of, 169 
varieties of, 167 
wandering, 167 
Exanthemata, the infectious, 

194 ff. 
Eyes, treatment of symptoms 
referable to in fever, 63 

Fahrenheit scale of thermometry, 

29 
Famine fever, see Relapsing 

fever 
Febrile disease, beverages in, 67 
feeding in, 64 ff. 



INDEX. 



2 5 T 



Feeding in febrile disease, 64 ff. 
Fever, adynamic, 11 

and ague, see Malarial Fever 

asthenic, 11 

causes of, 9 

continued, 11 

definition of, 9 

ciEr:::sis ::. 2$ 

dynamic, 11 

general treatment of, 42 

intermittent, 11 

inverse, 1 1 

physiology of, 10 

remittent, 1 1 

sores, 18 

sthenic, 11 

symptoms of, 17 ff. 

referable to the circu- 
latory system, 20 
mucous membranes, 

18 
nervous system, 22 
organs of digestion, 

19 
respiratory syste m, 

21 
the skin, 17 
the special senses, 

26 
urinary system, 22 
varieties of, 11 
Formaldehyde gar. as a disin- 
fectant, 80 
Fourth disease of Dukes. 220 
Furniture of the sick-room in 
febrile disease. 74 

German measles. 21 8 

causation of, 218 
course and symptoms 

of, 219 
definition of, 218 
diet in, 220 
eruption of, 219 
treatment of, 220 



German measles, prevention of, 
220 

Headache in fever, 2s 

treatment of, 61 
Hearing, symptoms of fever ref- 
erable to, 26 
Heat exhaustion, course and 
symptoms c£, 225 
see Thermic Fever 
treatment of, ;;" 
prostr:.:: :::. see Thermic 
Fever 
Heat-stroke, see Thermic Fever 
Hemorrhage, intestinal in en- 
teric fever, 100 
Hiccough in fever, 26 

treatment of, 62 
B : ; pital fever, see Typhus Fever 
Hydrotherapy in fever, 44 

Ice bags. 51 

coils. 5 : 

compresses, 51 

pack, the, 51 

rub, the. 5 : 
Influenza, 124 

causation ::. :__ 

complications of, 126 

course and symptoms of, 125 

definition of, 124 

diet in, 127 

prevention of, 126 

treatment of. :-~ 
Insolation, see Thermic Fever 
Intubation in diphtheria, 161 

Jail fever, see Typhus Fever 

La Grippe, see Influenza 

Lung fever, see Pneumonia 
Lysis in fever, 12 

Malarial fever. :$_ 

causation of, 183 

chronic. :$2. 1S7 
clinical chart of, 1S5 



232 



INDEX. 



Malarial fever, course and symp- 
toms of, 184 
definition of, 182 
estivo-autumnal, 182, 

183 
pernicious, 182, 186 
prevention of, 187 
quartan, 182, 183 
quotidian, 182, 183 
tertian, 182, 183 
treatment of, 187 
varieties of, 182 
Malignant adenitis, see Bubonic 
Plague 
purpuric fever, see Menin- 
gitis, Epidemic Cerebro- 
spinal 
Malta fever, 128 

definition of, 128 
diet in, 129 
causation of, 128 
complications of, 129 
course and symptoms 

of, 128 
prevention of, 129 
treatment of, 129 
Measles, 214 
black, 216 
causation of, 214 
clinical chart of, 216 
complications of, 217 
course and symptoms of, 215 
diet in, 218 
definition of, 214 
eruption of, 215 
hemorrhagic, 216 
prevention of, 217 
treatment of, 217 
Mediterranean fever, see Malta 

Fever 
Membranous croup, see Diph- 
theria, False 
Meningitis, epidemic cerebro- 
spinal, 220 
causation of, 221 



Meningitis, epidemic cerebro- 
spinal, complica- 
tions of, 223 
course and symp- 
toms of, 221 
definition of, 221 
diet in, 22Z 
eruption of, 222 
treatment of, 223 
varieties of, 223 
Morbilli, see Measles 
Mountain fever, 129 

causation of, 129 
course and symptoms 

of, 130 
diet in, 132 
eruption of, 131 
definition of, 129 
prevention of, 132 
treatment of, 132 
Mucous membranes, symptoms 
of fever referable to, 
18 
treatment of symptoms 
of fever referable to, 

55 
Mumps, 176 

causation of, 177 

course and symptoms of, 177 

definition of, 177 

diet in, 178 

prevention of, 178 

treatment of, 178 

Neapolitan fever, see Malta Fever 

Nervous fever, see Enteric Fever 

system, symptoms of fever 

referable to, 22 

treatment of symptoms 

of fever referable to, 

60 

Nose, treatment of symptoms 

referable to in fever, 62 
Nurse, behavior of in febrile 
disease, 77, 78 



INDEX. 



2 33 



Nurse, the, in febrile disease, 71 

Pains, general, in fever, 23 

in fever, treatment of, 
61 
Paludal fever, see Malarial Fever 
Paludism, see Malarial Fever 
Paratyphoid fever, 112 
Parotitis, epidemic, see Mumps 
Patient, care of in febrile dis- 
ease, 76 
Perforation of bowel in enteric 

fever, 100 
Pest, see Bubonic Plague 
Petechial fever, see Meningitis, 

Epidemic Cerebrospinal 
Phthisis, chronic, see Tubercu- 
losis, Chronic Pulmonary 
Pneumonia, 144 

causation of, 144 
clinical chart of, 147 
complications of, 146 
course and symptoms of, 145 
croupous, see Pneumonia 
definition of, 144 
diet in, 151 

fibrinous, see Pneumonia 
in infants, 148 
in old persons, 149 
prevention of, 149 
treatment of, 149 
varieties of, 148 
Pneumonitis, see Pneumonia 
Privies, disinfection of, 86 
Pseudo-diphtheria, see Diph- 
theria, False 
Puerperal fever, 173 

treatment of, 174 
infection, see Puerperal Fe- 
ver 
septicemia, see Puerperal 
Fever 
Pulse charting, directions for, 38 
dicrotic, 20, 35 
factors which influence, 21 
16 



Pulse, intermittent, 34 

irregular, 34 

normal, 35 

table of, 34 

qualities to be noted in 
taking, 34 

table of, with corresponding 
temperature, 20 

taking, 33 ff. 

tension of, 34 

thickening of artery in, 35 
Putrid fever, see Typhus Fever 

sore throat, see Diphtheria 
Pyemia, 175 

causation of, 175 

course and symptoms of, 175 

definition of, 175 

prevention of, 176 

treatment of, 176 

Reaumur, scale of thermometry, 

29 
Recrudescence in fever, 12 
Recurrent typhus, see Relapsing 

Fever 
Relapse in fever, 12 
Relapsing fever, 188 

causation of, 188 
clinical chart of, 190 
complications of, 190 
course and symptoms 

of, 189 
definition of, 188 
prevention of, 190 
treatment of, 191 
Respiration charting, directions 
for, 38 
normal, table of, 37 
qualities to be noted in 

taking, 37 
taking, 36 ff. 
Respiratory system, symptoms of 
fever referable to, 21 
treatment of symptoms 



234 



INDEX. 



of fever referable to, 
57 
Rheumatic fever, see Rheuma- 
tism, Acute Articular 
Rheumatism, acute articular, 163 
causation of, 163 
clinical chart of, 

165 

complications of, 

164 
course and symp- 
toms of, 163 
definition of, 163 
diet in, 166 
prevention of, 164 
treatment of, 165 
inflammatory, see Rheuma- 
tism, Acute Articular 
Rock fever, see Malta Fever 
Roseola, see German Measles 
Rotheln, see German Measles 
Rubella, see German Measles 
Rubeola, see Measles 

St. Anthony's fire, see Erysipelas 

Scarlet fever, 194 

anginose, 198 
causation of, 194 
clinical chart of, 197 
complications and se- 
quelae of, 199 
course and symptoms 

of, 196 
definition of, 194 
desquamation in, 198 
diet in, 202 
eruption of, 195 
hemorrhagic, 198 
malignant, 198 
prevention of, 200 
treatment of, 201 

Scarlatina, see Scarlet Fever, 194 

Septicemia, 170 

causation of, 170 

course and symptoms of, 171 



Septicemia, definition of, 170 
diet in, 172 
prevention of, 172 
treatment of, 172 
Seven-day fever, see Relapsing 

Fever 
Ship fever, see Typhus Fever 
Sick-room, the, in febrile disease, 

7i 
Sight, symptoms of fever refer- 
able to sense of, 27 
Sinks, disinfection of, 86 
Skin, symptoms of fever refer- 
able to, 17 
treatment of symptoms of 
fever referable to, 53 
Smallpox, 202 

causation of, 202 
clinical chart of, 205 
course and symptoms of, 204 
definition of, 202 
eruption of, 203 
hemorrhagic form of, 207 
malignant, 206 
prevention of, 207 
treatment of, 211 
Smell, symptoms of fever refer- 
able to sense of, 26 
Sordes in fever, 18 
Special sense, treatment of symp- 
toms of fever referable to or- 
gans of, 62 
Spirillum fever, see Relapsing 

Fever 
Spotted fever, see Typhus Fever, 
Mountain Fever and Menin- 
gitis, Epidemic Cerebrospinal 
Sputum, disinfection of, 85 
Steam as a disinfectant, 79 
Stools, disinfection of, 84 
Sulphur dioxid gas as a disin- 
fectant, 80 
Sunstroke, see Thermic Fever 
Swamp fever, see Malarial Fever 



INDEX. 



235 



Taste, symptoms of fever refer- 
able to sense of, 26 
Temperature, bodily, 12 ff. 
in axilla, 31 
in mouth, 31 
in rectum, 31 
limits of, 15 
ranges of, 16 
technique of taking, 3 iff. 
variations of, 13 if. 
charting, directions for, 38 
charts, 38, 39, 40 
table of, with corresponding 
pulse, 20 
Thermic fever, 225 

course and symptoms 

of, 226 
definition of, 225 
prevention of, 226 
treatment of, 227 
Thermometer, the, 28 
Thermometers, care of, 30 
Thermometry, scales of, 29 
Tick fever, see Mountain Fever 
Tongue, care of, 55 
Tracheotomy in diphtheria, 161 
Tuberculosis, acute general, see 
Tuberculosis, Acute 
Miliary 
miliary, 132 

causation of, 132 
course and symp- 
toms of, 133 
definition of, 132 
diet in, 134 
treatment of, 134 
varieties of, 133 
chronic pulmonary, 134 

causation of, 134 
course and symp- 
toms of, 134 
definition of, 134 
diet in, 140 
prevention of, 136 
treatment of, 138 



Tympanites in fever, treatment 
of, 56 

Typhoid fever, see Enteric Fever 

Typhus fever, 114 

causation of, 115 
clinical chart of, 117 
course and symptoms 

of, 115 
definition of, 114 
eruption of, 116 
prevention of, 118 
treatment of, 118 

Undulant fever, see Malta Fever 
Urinary system, symptoms of 
fever referable to, 22 
system, treatment of symp- 
toms of fever referable to, 
58 
Urine, disinfection of, 85 

retention of in fever, treat- 
ment of, 59 

Vaccination, 207 

complications of, 210 

technique of, 208 
Vaccinia, 209 

generalized, 209 
Varicella, see Chicken Pox 
Variola, see Smallpox 
Varioloid, 207 

Ventilation in febrile disease, 72 
Visitors in febrile disease, 77 
Vomiting in fever, treatment of, 
56 

Walking typhoid fever, 90 
Water-closets, drains, sinks and 

privies, disinfection of, 86 
Weil's disease, 113 

causation of, 113 
course and symptoms 

of, 113 
definition of, 113 
diet in, 114 



236 



INDEX. 



Weil's disease, treatment of, 

114 
Widal reaction, the, in enteric 

fever, 102 

Yellow fever, 119 

causation of, 119 
clinical chart of, 121 



Yellow fever, complications of, 

122 
course and symptoms 

of, 120 
definition of, 119 
diet in, 124 
prevention of, 122 
treatment of, 123 



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Gould's Medical Dictionaries, 
Morris' Anatomy, - ' - 

Compends for Students, - 



Pages 12, 13 
Page 4 
Page 27 



SUBJECT. PAGE 

Alimentary Canal (see Sur- 
gery) 24 

Anatomy .............. 7 

Anesthetics 18, 19 

Autopsies (see Pathology) 20 

Bacteriology 8 

Bandaging (see Surgery) . . 24 

Blood, Examination of . . . 8 

Brain 8 

Bright's Disease 26 

Chemistry. Physics .... 9 

Children, Diseases of 11 

Climatology 19 

Clinical Charts 25 

Compends 27 

Consumption (see Lungs) . 16 

Cyclopedia of Medicine ... 13 

Dentistry 11 

Diabetes (see Urin. Organs) 25 

Diagnosis 11 

Diagrams (see Anatomy) . 8 

Dictionaries, Cyclopedias, 12 

Diet and Food 13 

Disinfection 16 

Dissectors 7 

Ear 14 

Electricity 14 

Embryology 7 

Emergencies 24 

Eye 14 

Fevers 15 

Food 13 

Formularies 21 

Gynecology 15 

Hay Fever 25 

Heart 15 

Histology 15 

Hydrotherapy 19 

Hygiene 16 

Hypnotism 8 

Insanity 8 

Intestines 23 

Latin, Medical (see Phar- 
macy) 21 

Life Insurance 19 

Lungs 16 

Massage 17 

Materia Medica 17 

Mechanotherapy 17 



SUBJECT. PAGE 

Medical Jurisprudence .... 18 

Mental Therapeutics 8 

Microscopy 18 

Milk 8, 10 

Miscellaneous 18 

Nervous Diseases 19 

Nose 25 

Nursing 20 

Obstetrics 20 

Ophthalmology 14 

Organotherapy 18 

Osteology (see Anatomy). 7 

Pathology 20 

Pharmacy 21 

Physical Diagnosis 11 

Physical Training 17 

Physiology 22 

Pneumotherapy 19 

Poisons (see Toxicology) . . 18 

Practice of Medicine 22 

Prescription Books (Phar- 
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Refraction (see Eye) 14 

Rest 19 

Sanitary Science n* 16 

Serum-Therapy 17 

Skin 23 

Spectacles (see Eye) 14 

Spine (see Nervous Dis- 
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Stomach 23 

Students' Compends ..... 27 
Surgery and Surgical Dis- 
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Technological Books 9 

Temperature Charts 25 

Therapeutics 17 

Throat 25 

Toxicology 18 

Tumors (see Surgery) .... 24 

U. S. Pharmacopoeia 22 

Urinary Organs 25 

Urine 25 

Venereal Diseases ........ 26 

Veterinary Medicine 26 

Visiting Lists, Physicians'. 
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Water Analysis 16 

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DICTIONARIES. CYCLOPEDIAS. 

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MEDICAL BOOKS. 13 

GOULD. The Pocket Pronouncing Medical Lexicon. 4th Edi- 
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George M. Gould, m.d., Author of "An Illustrated Dictionary 
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14 SUBJECT CATALOGUE. 

EAR (see also Throat and Nose). 

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MEDICAL BOOKS 15 

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16" SUBJECT CATALOGUE. 

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MEDICAL BOOKS. 17 



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18 SUBJECT CATALOGUE. 

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MISCELLANEOUS. 

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COHEN. Organotherapy. See Cohen, Physiologic Therapeutics, 

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MEDICAL BOOKS. 19 

GREENE. Medical Examination for Life Insurance. Illus. 
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20 SUBJECT CATALOGUE. 

NURSING (see also Massage). 

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HADLEY. General, Medical, and Surgical Nursing. A very 
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HUMPHREY. A Manual for Nurses. Including General 
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STARR. The Hygiene of the Nursery. Including the General 
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TEMPERATURE AND CLINICAL CHARTS. See page 25. 
VOSWINKEL. Surgical Nursing. Second Edition, Enlarged. 
112 Illustrations. $1.00 

WILCOX. Fever Nursing. Just Ready. $1.00 

OBSTETRICS, 

EDGAR. Text-Book of Obstetrics. By J. Cmfton Edoar, 
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Department of Cornell University, New York City, etc. 1221 
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FULLERTON. Obstetric Nursing. 6th Ed. Illus. $1.00 

LANDIS. Compend of Obstetrics. 7th Edition, Revised by 
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WINCKEL. Text-Book of Obstetrics, Including the Pathology 
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PATHOLOGY. 

DANIEL. Laboratory Exercises in Tropical Medicine. Just 
Ready. $4.00 

BLACKBURN. Autopsies. A Manual of Autopsies Designed 
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COPLIN. Manual of Pathology. Including Bacteriology, Tech - 
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MEDICAL BOOKS. 21 

DA COSTA. Clinical Hematology. A Practical Guide to the 
Examination of the Blood. Six Colored Plates and 48 Illus- 
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LAZARUS-BARLOW. Pathological Anatomy. With 7 Colored 
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MacLEOD. The Pathology of the Skin. Colored and other 
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ROBERTS. Gynecological Pathology. Illustrated. $6.00 

THAYER. Compend of Special Pathology. Illustrated. 

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VIRCHOW. Post-Mortem Examinations. 3d Edition. .75 

WHITACRE. Laboratory Text-Book of Pathology. With 121 
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COBLENTZ. Volumetric Analysis. Illustrated. $1.25 

BEASLEY. Book of 3100 Prescriptions. Collected from the 
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10th Edition. $2.00 

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GREENISH. Microscopical Examination of Foods and Drugs. 
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SAYRE. Organic Materia Medica and Pharmacognosy. An 
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Physical Characteristics, Source, Constituents, and Pharma- 
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MEDICAL BOOKS. 23 



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MEDICAL BOOKS. 25 

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27 



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Clinical Hematology 

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Manual of Pathology 



GENERAL AND SPECIAL 

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28 



The Pocket Cyclopedic of 
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Uniform *wiih " Gould's Pocket Dictionary " 



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29 



A NEW EDITION 



Crocker on the Skin 



The Diseases of the Skin. Their Description, Pathology, 
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STURG1S— MANUAL OF 
VENEREAL DISEASES 



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30 



FOR THE DISSECTING ROOM 

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31 



EDGAR'S 

OBSTETRICS 

A NEW TEXT -BOOK 
1 22 1 Illustrations 



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OCTAVO. CLOTH, JS6.00; SHEEP, $7.00 



